Bridging the gaps: Addressing post-hospital vulnerability and long COVID in rehabilitation practice

We read with great interest the recent qualitative study by Murphy et al., titled “An exploration of the patient experience of rehabilitation post COVID-19 infection during the first wave: A qualitative study.” ¹ The study offers valuable insights into the lived experiences of individuals recovering from COVID-19 during the first wave of the pandemic (March–August 2020). By identifying four central themes, the authors illuminate the complexities of the recovery process—extending from the acute phase through inpatient rehabilitation and onward to community reintegration. Among these, two themes—“transitioning home after hospitalization” and “long COVID syndrome”—stand out as critical junctures requiring deeper reflection and strategic intervention.

The theme of transitioning home reveals a particularly fragile phase in the rehabilitation journey. Many participants described feeling anxious, physically unready, and insufficiently supported following hospital discharge. This period represents a liminal gap, where formal clinical oversight ends, yet functional and psychosocial recovery is still far from complete. As noted by the authors, “the process of returning home was not always smooth,” with patients articulating a sense of heightened vulnerability. These findings are echoed in the broader literature; for instance, previous studies have reported that poor discharge preparedness—characterized by limited communication and inadequate post-hospital support systems—left many patients feeling adrift.^2,3 A recent meta-analysis found that up to 60% of COVID-19 survivors continue to experience persistent symptoms 6 months post-infection, such as fatigue, cognitive impairment, and breathlessness, significantly affecting their quality of life and ability to reintegrate into society.^4,5 Furthermore, the economic burden on healthcare systems is increasing as patients require long-term rehabilitation. ⁶

Considering these observations, we propose the implementation of a structured, physiotherapist-led transitional care model—integrated with ongoing follow-up and community-based rehabilitation. This hypothesis finds empirical support in the work, that such programs effectively reduce readmission rates while enhancing patient confidence and independence at home. ⁷ Given these observations, we propose the implementation of a structured, physiotherapist-led transitional care model—integrated with ongoing follow-up and community-based rehabilitation. This model has been successfully adopted in several countries, such as the United Kingdom and Canada, where interdisciplinary rehabilitation programs combining physiotherapy, psychological support, and community reintegration have demonstrated improved patient outcomes and reduced readmission rates. ⁸ A feasible model may involve initiating follow-up contact within 2 weeks of discharge, incorporating symptom-specific assessments, personalized goal setting, and motivational support. This approach provides a practical, resource-conscious means of extending the continuum of care, especially for the vulnerable post-COVID populations.

Equally significant is the theme of long COVID syndrome, which highlights the enduring impact of post-viral symptoms and the frequent disconnect between patient experiences and provider recognition. Participants in the study by Murphy et al. reported persistent issues such as fatigue, breathlessness, and cognitive impairment—yet often felt these were minimized or insufficiently addressed within standard care protocols. That more than 60% of COVID-19 survivors continued to experience at least one symptom 6 months post-infection,^9–11 with studies showing that long COVID symptoms significantly impair daily functioning, mental health, and employment prospects.^12,13

Despite increased attention to long COVID, there remains a pressing need to translate such insights into actionable physiotherapy frameworks. A recent global survey found that fewer than 40% of post-COVID rehabilitation programs include interdisciplinary teams that address the complex needs of long COVID patients, such as psychological support, cognitive rehabilitation, and pulmonary therapy.^14,15 This gap underscores the critical need for integrated, patient-centered rehabilitation pathways.

We therefore recommend integrating routine symptom screening tools—such as fatigue inventories and breathlessness scales—into discharge planning, coupled with clearly defined referral pathways for cognitive and pulmonary rehabilitation. Such modular integration refers to the deliberate incorporation of psychological and neurological components into rehabilitation programs, emphasizing the need for a comprehensive approach beyond cognitive and pulmonary rehabilitation. ¹⁶ That standardized symptom tracking improved physiotherapists’ capacity to tailor interventions for long COVID patients. ¹⁷

What distinguishes our perspective is the emphasis on embedding rehabilitation within a continuous and adaptive care trajectory, rather than treating it as a discrete, time-limited intervention. Structured multidisciplinary discharge pathways significantly mitigated post-discharge anxiety and enhanced long-term outcomes among COVID-19 survivors. ¹⁸ The study by Murphy et al. gives voice to patients’ experiences; our commentary seeks to operationalize those voices into sustainable, scalable practices. These include coordinated transitional physiotherapy services with interdisciplinary collaboration, and standardized rehabilitation tracks for managing complex post-viral sequelae.

Further, fatigue-focused modules—delivered via remote platforms—helped patients regain daily functioning more effectively, ¹⁹ the importance of emotional validation and clear guidance in helping patients reclaim agency during the home transition phase. ²⁰

Finally, we advocate for the integration of long COVID care into mainstream physiotherapy services, as this approach can improve access to care, reduce stigma, and strengthen therapeutic trust. In our view, achieving a truly responsive rehabilitation paradigm in the post-pandemic era requires sustained commitment to continuity, individualization, and systemic readiness, particularly for complex and evolving conditions such as long COVID.