Continuum of rehabilitation services across 12 low-income, middle-income and high-income countries in the context of national COVID-19 preparedness recommendations
| Country | National government mandated COVID-19 response | Rehabilitation services during COVID-19* (inpatient, redeployment/bed shift, outpatient/home and telehealth) | ||
| Stay-at-home order 2020 | National response | Guidance for ‘non-essential’ healthcare services | ||
| Argentina | 20 March | National lockdown: essential trips for cleaning supplies, medicines and food. | Outpatient suspended. | Inpatient rehabilitation still offered in reduced capacity. Other inpatient bed types converted to increase acute hospital bed capacity. Patients are not attending day rehabilitation programmes despite programmes being open. All outpatients clinics in all public and private hospitals closed. Physicians and therapists cannot get reimbursed for video telehealth visits (neither video nor telephone). |
| Belgium | 17 March | Containment and mitigation: school and retail closures, ban on all gatherings, movement only for essential needs and ban on non-essential international travel. | Non-essential services suspended. | Inpatient rehabilitation operational but discharging more quickly to prevent spread; all activities in patients’ room. Rehabilitation personnel but not beds have shifted to support acute care. All outpatient rehabilitation services discontinued. Government-approved renumeration for telerehabilitation for all provider types (expanded for COVID-19). |
| Brazil | By state | Containment and mitigation: national guidance defined essential services and recommendations for social distancing and foreign entry restricted. | Non-essential services suspended. | Reduced operations for inpatient rehabilitation. Shift in rehabilitation personnel and outpatient services, encouraged to use telemedicine. Federal Council of Medicine acknowledges use of telemedicine for teleorientation (distance guidance, training and patient referral), telemonitoring under medical supervision or guidance and teleinterconsultation (between physicians for diagnostic or therapeutic assistance). |
| China | 23 January | Lockdowns across country: suspension of travel, banned public gatherings, early detection and isolation, mobility restrictions and quarantine for returning migrant workers. | Non-essential services suspended. | Inpatient rehabilitation for all non-urgent patients suspended. Shift in rehabilitation hospital beds or rehabilitation personnel to help with COVID-19 response. Outpatient rehabilitation suspended. All home care discontinued. Teleconsultation/virtual rehabilitation provided mostly free of charge. |
| Germany | 22 March | Containment and mitigation: travel restrictions, school closure, closing non-essential businesses and banned public gatherings. | All elective surgeries and non-essential services postponed. | Acute hospitals continued early acute rehabilitation. Rehabilitation hospitals discontinued care for chronic, non-acute problems; acute patients (eg, surgery and stroke) stay as long as needed. Some rehabilitation hospitals could be designated as overflow hospitals. Rehabilitatation personnel supporting acute hospitals. Outpatient rehabilitation is reduced but available for high need patients/essential care. Telerehabilitation for physicians and health professionals in the acute COVID-19 phase possible and reimbursed. |
| Guyana | 16 March | Encouraging social distancing and hygienic practices. Established health emergency operations centre. Curfew and stay-at-home policy implemented and all non-essential business ordered closed. | All elective surgeries and non-essential services postponed. | Inpatient rehabilitation continued in acute hospitals. Outpatient rehabilitation therapists reassigned to acute hospitals. All community-based rehabilitation suspended in hinterland regions. Phased approach to cancelling/closing all outpatient rehabilitation services; patients receive self-led home-based programme. Telerehabilitation via telephone, Zoom, WhatsApp and emailing exercise programs. Also using MedBridge. |
| India | 24 March | National lockdown: exceptions medical and pharma services, groceries, banks, telecom, gas stations as essential services, school closures and restriction of international and most domestic travel. | Non-essential elective surgeries postponed | Hospitals discharging stable patients at earliest possible. Inpatient rehabilitation continued for patients who cannot return or travel home. Rehabilitation personnel considered part of human resource mobilisation for training and possible role assignments. Outpatient and home-based rehabilitation suspended. Telerehabilitation via phone, Whatsapp and Zoom carried out by certain tertiary care and independent rehabilitation clinics especially for the neurologically ill patients. |
| Singapore | 7 April | National lockdown: temp. screening, hospital and home quarantines, extensive tracing, social distancing, bans on large gatherings, schools closed and travel restricted. | Non-essential appointments, including elective procedures and outpatient rehabilitation, deferred. | Inpatient rehabilitation continued but location shifted outside of acute hospitals into stand-alone rehabilitation (community) hospitals. Focus on intensive care, cardiopulmonary and severe, new onset disability. A significant proportion of outpatient providers shifted to inpatient. Limited outpatient rehabilitation personnel focused on postacute and shifted to small teams for physical distancing. All group and community-based rehabilitation activities suspended including day rehabilitation and senior activity centres. Home rehabilitation requests subject to review by health authorities, restricted to patients with significant new-disability and limited caregiver support. In-hospital rehabilitation consults and multidisciplinary team meetings through teleconference. Providers trained to deliver teleconsultations with national regulatory guidance for quality and cybersecurity. |
| Spain | 14 March | National lockdown: exceptions medical and pharmacy services, groceries and banks. School closures and restriction of international travel. | Non-essential services suspended, non-urgent surgeries postponed and outpatient clinics closed. | Inpatient rehabilitation offered in reduced capacity. Rehabilitation beds shifted to extend capacity of acute care. Outpatient rehabilitation programmes suspended. All outpatient clinics in all public and private hospitals closed. The majority of home-based rehabilitation (but not completely) suspended. Physicians and therapists cannot get reimbursed specifically for telehealth visits (neither video nor telephone as of 23 April). In some contexts (eg, Catalonia) the Board of Physical Therapists organised a task force of volunteer physical therapists who can deliver some telephone-based rehabilitation. (Provision of healthcare is regulated and reimbursed regionally.) |
| Tanzania | Local only | Containment and mitigation: public gatherings ban, 30-day closure of schools, universities, training institutions, health screening at points of entry, 14-day quarantine for travellers from high-risk countries. | Local KCMC. Example: care for older adults suspended unless an emergency, outpatient block appointments, reduced elective surgeries and prioritised emergency surgeries. | Inpatient rehabilitation offered but length of stay and visitors reduced to prevent hospital acquired infection (affecting amount of time therapists have to evaluate and treat patients+train family for home-based rehabilitation). Shift in rehabilitation personnel with those age >55 years exempt from patient contact. Outpatient rehabilitation appointments scheduled in blocks to avoid overcrowding and congestion especially in waiting areas. Telehealth not a standard of practice for rehabilitation (and not covered by insurance); patients discharged early and appointments delayed/cancelled have limited access to care. |
| USA | By state or city | Stay at home orders, school closures, bans of mass gatherings and non-essential business closures. | Recommendations to postpone all elective surgeries and non-urgent procedures and visits. | Fewer rehabilitation beds; beds converted for acute care. Shift in rehabilitation personnel to acute inpatient and telemedicine follow-up. Outpatient rehabilitation available only for high need patients following. CDC recommendations for essential care. Rehabilitation teleconsultations. Slow scale to virtual visits. Physicians reimbursed. Therapists reimbursed by some private insurers but not reimbursed by government insurance until 30 April. |
| UK | 23 March | National lockdown: only leave home for food, health reasons, work and other travel restrictions. Social distancing and personal hygiene guidelines. | Non-urgent surgeries postponed. | Hospital inpatients medically fit discharged early; inpatient rehabilitation offered in reduced capacity. Shift in rehabilitation hospital beds to maximise inpatient capacity; shift in rehabilitation personnel to provide greater acute hospital and community service support. Outpatient rehabilitation at reduced capacity. Telephone and digital/video-based consultation. |
*Authors provided reports of rehabilitation practice in the absence of national policies.
CDC, Centers for Disease Control and Prevention; KCMC, Kilimanjaro Christian Medical Center.