The pandemic caused by the new SARS-CoV2 was responsible for the death of more than 579,010 Brazilians and 4,470,969 people worldwide until August 28, 2021, despite the lack of adequate reporting of deaths in some countries. Additionally, thousands of people died without confirmed diagnosis of COVID-19, and part of the population still feels discouraged to seek hospital treatment due to precarious health care conditions and reduced access.1 Besides impacts caused by mortality, the period of hospitalization due to the disease and complications four to twelve weeks (on average) after infection led to thousands of individuals with physical, functional, emotional, and cognitive impairments. This condition is called post-COVID-19 syndrome, persistent post-COVID-19 syndrome (PPCS), or long COVID.2,3

This syndrome represents a grey area of scientific knowledge regarding COVID-19. If, on the one hand, attention is given to prevention and elimination of the disease, on the other hand, thousands of people face its sequelae after overcoming the infectious phase. These people must also adapt to a “new health condition”, which may aggravate underlying chronic diseases.2,3

In this scenario, the World Health Organization created a guideline on how cities should include strategies for rehabilitation of these patients in the national emergency health planning for COVID-19. Thus, this letter to the editor aims to alert the scientific community, health managers, and society about the need for early screening and continuity of multidisciplinary care in post-COVID-19 syndrome, especially in patients with high risk factors for developing long COVID, such as those who required hospitalization.4

Although hospital discharge is a reason to celebrate, few services provide de-hospitalization or guidance regarding next steps and further health care. This generates a false expectation that everything has been overcome. To date, more than 50 different types of post-COVID-19 sequelae were already confirmed, despite mortality due to these sequelae when patients are not well managed or treated.3

Below, we propose an initial model to maintain a line of multidisciplinary care based on previous studies3–5:

• 1.

  Identify patients with higher risk factors for developing post-COVID-19 syndrome. Priority should be directed to patients who were hospitalized in intensive care units or had prolonged hospital length of stay;

• 2.

  Clinical, functional, nutritional, and psychological check-up before hospital discharge, guidance for reassessment within the first 30 days after discharge, and periodic reassessments at least in the first year;

• 3.

  Create public and private reference services for rehabilitation of these patients (whether individual or group face-to-face care), home care, or teleconsultation/telerehabiliation, and refer patients to these locations at hospital discharge;

• 4.

  Implement screening and treatment for all levels of health care.

Continuity of care, especially rehabilitation, is essential and urgent for individuals with post-COVID-19 syndrome. In the same way that an international task force rapidly searched for disease prevention, the time has come to join efforts to mitigate sequelae and restore functionality and quality of life of those affected.