The second wave of COVID (Coronavirus Disease) in India in April-May 2021 posed one of the most significant challenges to the healthcare workers, infrastructure and system. At that time, though vaccination had begun, India, with a 1.3 billion population, had vaccinated around 10 million health and frontline workers with both vaccine doses, and about 70 million people aged 45 years and above with the first vaccine dose [1]. Therefore, most of the population was still not immunized at the onset of the second wave, which also brought in variants of concern (VOCs) like Delta and Alpha strains [2]. In contrast to the first wave, the second wave saw a predominance of younger age groups below 60 years, with often multiple family members or entire families getting affected.

The crucial need of the time was informed and balanced decision making by medical practitioners to prevent unnecessary overloading of healthcare resources and giving hospital care to those in real need. This required timely identification of patients with risks and alert signs for hospitalization and oxygen therapy and managing the majority of COVID cases which were mild, effectively in homecare. The general practitioners (GPs) and family physicians (FPs) are the backbones of healthcare in India, and they are the first point of contact for patients. Therefore, they form the firm foundation on which effective COVID management of the community rests. It is essential for GPs and FPs in each region to be trained, updated and have common platforms or chat groups created to discuss cases and share insights and experiences. Digital, and virtual medical care through tele/e-consultation and monitoring, evolved significantly in the pandemic, helping doctors and patients in safer, more convenient and comfortable healthcare [3]. Elaborated here and suggested for GPs and FPs is a systematic and virtual homecare management approach to treatment, monitoring, and 3-month post-COVID follow up for treating COVID patients in-home care. The results are discussed for patients managed by this approach who had symptomatic COVID in April 2021.

Setting: The clinical setting for COVID management of cases represented here is homecare with virtual digital treatment and monitoring by the physician.

Blanket prescriptions or unnecessary and over medication was guarded against, and the same was also discussed with patients, as adverse effects of too many drugs can often eclipse the actual day to day improvement in the COVID disease course and lead to apprehensions and wrong clinical decisions.

Disease Course, Scoring and Decision Making: With daily charts of continuous meticulous patient monitoring, hospitalization was to be considered immediately on any day of the course of the illness if symptoms of breathlessness or chest pain/pressure appeared, oxygen saturation was constantly <94% not improving by proning or dropping anytime below 90% (corresponding to pO2 of 60mm Hg below which there is a steep drop in the oxygen dissociation curve) [6]. Hospitalization was also recommended in altered mental status, significant weakness, or inability to eat or take medicines orally. In the absence of these signs, and the patient doing satisfactorily in homecare in the first week (viral phase), a planned reassessment was done at the beginning of the second week (host inflammation phase) with a review of clinical symptoms, oxygen saturation trends, and laboratory investigations of CBC, CRP, and blood sugar. Other inflammatory markers, including D-dimer and IL-6, were not recommended in homecare non-hospitalized patients. Informed decision making on further course and intervention at the end of the first week was made as follows:

Group A: If symptoms were reducing (fever <101 deg F responding to paracetamol, cough and sore throat improving) and oxygen saturation maintained >94% at all times, then monitoring and observation was continued without any additional intervention.

Group B: These patients had symptoms continuing into the second week, with some fever readings >101 deg F but responsive to paracetamol, or persistent cough, and significantly raised CRP (above five times of upper limit of normal). However, oxygen saturation was maintained at>94% at all times. They were monitored closely and were also offered the option of inhaled corticosteroids (budesonide).

Group C: In such patients, fever and cough symptoms had not significantly improved and were still prominent in the second week with high CRP, and oxygen readings often borderline (92-94%) but improving with proning. These patients were given a short 5-7 days course of low dose oral corticosteroids (methylprednisolone 16-32 mg/day).

It was advised to begin with less rigorous activities like simple stretches, guided yoga, outdoor walking at an average pace, and spot exercises for neck-shoulder, arms, legs, and abdomen, then step up gradually every week to reach one's average level of physical exercise over 3-6 months. Patients were asked to continue alternate breathing exercises, proning and oxygen saturation checks once daily. A home incentive respirometer was suggested in required cases.

Patients were also encouraged to seek counselling or support groups for post-COVID stress and anxiety. COVID vaccination, if incomplete or not done, was recommended three months post-recovery following national guidelines [15]. Patients who received oral corticosteroids were asked to repeat CBC and blood sugar at one month. Other post-recovery investigations were not routinely advised for those recovered in homecare except when comorbidities or strongly suggestive symptoms were present.

Ethics and Consent: All data was collected, structured and analyzed by ethical principles and guidelines, following patient confidentiality norms and consent.

For most family physicians, the period of the second COVID wave comprised of guiding and answering queries of a large number of people (patients, relatives, friends, and their referred known ones) every month. One hundred fourteen (114) patients sought direct consultation for confirmed symptomatic COVID in April 2021 and were initiated into homecare management. Among these, retrospectively analyzed here are 63 patients (41 male) in the age group 18-60 years who completed the entire treatment and monitoring period as prescribed, without deviations, self-medication initiation/modification, or multiple medical/non-medical opinions. Fifty-one (51) patients also completed a 3-month post-COVID follow-up.

Out of the 63 patients treated in homecare, 29/63 patients were <45 years of age, while comorbidities were present in 14 patients (12 of them in the 45-60 age group). None of the patients had received the COVID vaccine. With respect to comorbidities, 7 patients had diabetes, 2 had asthma, 6 had hypertension, and 4 had diabetes and hypertension with a history of CVD (angina/myocardial infarction, angioplasty/bypass graft).

Group A: Symptomatic improvement, maintained oxygen saturation and no additional intervention in the 2^nd week.

Group B: Continuing symptoms, maintained oxygen saturation and close monitoring in the 2^nd week.

Group C: Symptoms not improving, evidence of mild hypoxemia and needing oral corticosteroids in 2^nd week.

Group D: Worsening symptoms, hypoxemia and requiring hospitalization.

Refer text under methodology for detailed group descriptions

Out of 51 patients who followed up for post-COVID health for three months, 47 patients had some post-COVID symptoms in the first month, 39 continued to have some symptoms in the 2^nd month, 17 had some symptoms in the 3^rd month, and three patients continued to have some symptoms suggesting long COVID (figure 2). The common post-COVID symptoms seen (table 2) were general lethargy, fatigue, low energy and weakness; headache, body ache or joint pains; feverish feeling or mild fever; gastrointestinal (GI) symptoms like indigestion, low appetite, and nausea; reduced taste/smell; feeling breathless especially after physical exertion like exercise, climbing stairs, etc.; palpitations; sleeplessness (insomnia); brain fog (feeling mentally less sharp, forgetful); hair loss; and anxiety-depression. Most patients were managed conservatively with diet, lifestyle modification, breathing techniques and home incentive respirometer, rest and graded physical activity, and emotional reassurance. Probiotics, protein and vitamin-mineral supplements (vitamin B-zinc-selenium-chromium, vitamin C, vitamin D weekly, and iron-biotin in case of hair loss), and SOS analgesics like paracetamol were given in some patients. Medicines for sleep were prescribed for a limited period in low doses in 5 patients, while 4 patients were suggested counselling/therapy for anxiety-depression. While 3 patients were recommended a 2-D echocardiogram which was normal, 1 patient was investigated with both HR-CT chest and echocardiogram and referred for specialist care due to the presence of diabetes, blood pressure and history of coronary artery bypass graft (CABG). Blood sugar did not show any abnormality in the follow up of the seven patients who received oral corticosteroids. No patient reported alarm signs/symptoms or developed any thrombotic complications or Mucormycosis.

All this contributed to patient apprehensions on why a particular medicine was not being prescribed when it was perhaps there on other prescriptions. Getting excess laboratory tests done and the associated panic and anxiety led patients to self-medicate or pressurize physicians into starting antibiotics, favipiravir, even corticosteroids, and in some cases directly acting oral anticoagulants (like apixaban), in the absence of clinical need, and despite imparting reassurance, counselling and detailed explanations [16-18]. Therefore almost 45% (51/114) of patients treated in homecare could not be taken for analysis here due to such deviations.

A well-defined and systematic approach for assessment, monitoring and treatment can only be effective if coupled with proper care, compliance and confidence from the patient with the support of family and caregivers. With the mentioned clinical approach and patient parameters here, only 2 patients required hospitalization, and corticosteroids were given only when hypoxemia was recorded with persistent symptoms and high CRP. Corticosteroids in the absence of hypoxemia have not shown clinical benefit and are not recommended [19]. However, generally, a large number of patients during the 2^nd wave took corticosteroids in the 2^nd week, or even earlier in the viremic phase if highly symptomatic, often with prolonged duration of dosing [17]. This led to a more adverse result with immunosuppression, increased blood sugar, and risk of opportunistic infections like Mucormycosis in the community [20]. Rampant and blanket use of antibiotics in all cases can give rise to significant future antimicrobial resistance and unnecessary adverse effects [16]. In the cases given an antibiotic here for suspected bacterial sore throat, as a deduction in hindsight, some could have been managed with antiseptics gargles alone. Ivermectin was given to all based on national guidelines and the advantage of low cost, short course duration, accepted tolerance and adequate availability [8]. Based on the evidence for favipiravir in reducing viral load and days of illness, it was given to the patients who were initially highly symptomatic or had associated comorbidities [9]. This drug has a high cost, high pill burden and longer dosing duration. No correlation was seen between the viral load by RT-PCR cycle time (Ct) and the severity of clinical symptoms.

Meticulous clinical monitoring and maintaining oxygen saturation and daily symptom charts, along with awake proning, are the cornerstones of management.

The key was a systematic and rational approach to treating, monitoring and managing COVID patients at home for better care and recovery and to limit unnecessary hospitalization. Diet and lifestyle measures, documentation of oxygen saturation and temperature monitoring, proning and breathing techniques, and psychological support are of great importance that not only aid recovery but also enable sound clinical evaluation and decisions with avoidance of undue over-prescription of drugs and tests. Post-COVID symptoms were also seen to subside in most cases by three months with conservative health measures.

Holistic management of COVID by the physician (instead of prescription medicine practice only), meticulous monitoring and follow-up utilizing digital means effectively, structured and timely stratification of patients and informed decision making can significantly improve COVID management in homecare for both the family physician and patient, as well as minimize clinical deterioration, complications and need for hospitalization. This also helps strengthen the foundation of healthcare and reduce the severe burden on in-patient doctors and infrastructure. Sharing such data, insights and experiences by family physicians can further help refine the approach to treatment and improve patient care.