An alternate level of care (ALC) patient is a designation made by a physician to describe a patient who occupies a hospital bed but does not require the intensity of resources or services provided in an acute care setting. ALC patients result in an inefficient use of hospital resources.1 The bottleneck caused by ALC patients creates a health system level problem by affecting a hospital’s ability to care for acutely ill patients.2 Any solution to an excess of ALC patients must recognize the unique role and the restricted capacity of acute care hospitals. Reducing inpatient ALC will increase acute care hospitalizations for the same total number of beds.3
ALC is one of the most pressing public health issues in Ontario. ALC and its effect on hospital bed occupancy rates have an important impact on the Ministry of Health and Long-Term Care (MOHLTC) today and over the next five years. The three dimensions of the ALC issue that are most critical to address include increased community capacity to care for people outside of the hospital setting, Emergency Room (ER) wait times and the aging population. ALC is a long-standing, multifaceted, system-wide issue with severe implications for healthcare in Ontario.
BACKGROUND & CURRENT STATUS
Historically, ALC has been identified as a hospital problem. It has become increasingly evident that it is a system issue that cannot be resolved by hospitals alone.4 Beginning in 2009, all hospitals in Ontario were expected to designate patients as ALC according to the provincial ALC patient definition.5 ALC is a continuously monitored metric to assess how well the health system and its partners in acute and community-based care are working to provide seamless care for residents.6 A lower rate is better, which is currently not the case.
The challenges characterized by this issue in hospitals relate to the following issues and observations: overcrowding, patient flow, access, integration, capacity, and resources.7 The inappropriate placement of non-acute patients in acute care beds results in a ripple effect causing decreased access to acute care, cancellation of elective surgery and excessive ER wait times for inpatient beds for acutely unwell patients. 8 ALC is a complex, serious system issue, which impacts patients access to acute care, patient safety, and patient quality of life.9 Most ALC patients are over 75 years of age.5 ALC has a negative effect on the health and well-being of a patient and their families and is very costly to the healthcare system.
Increased Community Care Capacity to Care for People Outside the Hospital
ALC is typically seen for patients waiting for placement primarily in long-term care (LTC), in addition to chronic care, rehabilitation and convalescent care facilities, and in-home care programs.10 The lack of placement options that meet the requirements of ALC patients outside the hospital is the main reason why ALC patients are not discharged from the hospital when they no longer need acute care. Overcrowding in Ontario hospitals has become so serious “that the sector is ‘on the brink’ of a ‘crisis.'”11 Bed occupancy rates at some hospitals were as high as 140% while the international standard for safe occupancy is 85%.11
Over the past two years, the number of patients waiting as inpatients for ALC has increased 16%.12 There are approximately 4,500 patients waiting to receive care in a more appropriate setting, and more than half of them are waiting for LTC.13 The average hospitalized patient in need of LTC spends 68 days waiting.13 Ontario’s Auditor General Bonnie Lysyk found that more than 4,100 of Ontario’s 31,000 beds are being occupied unnecessarily by patients waiting for LTC or home care.14 While hospitalized, it is common for ALC patients to experience a decline in their overall health and well-being.8 The Ontario Hospital Association (OHA) blames the acute-care overcrowding on a shortage of available LTC and home care.15
Emergency Department Times
The OHA stated that 90% of patients in the ER wait 37 hours or less for hospital beds, and 23 hours or less for intensive care beds.14 Acute care areas are being re-purposed as holding areas for ALC patient. Acute care patients cannot be admitted and the consequences of this are congested ERs with long wait times, crowded wards, and delayed or canceled procedures.1,16 If fewer hospital beds were occupied by ALC patients, they could be used immediately for admitted patients from the ER, thus decreasing overcrowding. ER wait times “are a critical barometer for how the healthcare system is functioning and the warning alarm is sounding loudly.”11
Some patients may choose to stay in a convenient and safe acute care hospital rather than move to a less desirable LTC facility. The OHA has been working with the MOHLTC to find and develop innovative solutions that address this issue.12 These efforts are aimed at alleviating the health system pressures related to ER and ALC, improving wait time and enhancing overall access to care.5
Recently, it was announced that there will be an additional 1,200 acute care hospital beds available in Ontario in preparation for a surge in demand due to the flu season.18 This is a short-term solution and is not going to solve this crisis in the long-term. This issue is going to be dealt with by constant, persistent investment in the healthcare system and hospitals.15
One of the most pressing policy mandates of our time is Canada’s aging population, which is growing quickly. Individuals are living longer with frailty and more complex medical needs.12 As a result, the ALC population is expected to grow considerably.4 The OHA notes that the number of annual visits to the ER is likely to increase by 30% over the next 25 years.13 Most ALC patients are over the age of 75, this demographic is expected to grow by a staggering 32% over the next 10 years.5 By 2021, over 130,000 LTC home beds would be required if demand continues to grow at this rate in the future.1 The MOHLTC has made important strides in implementing programs to address the ALC challenge, however, there are still further opportunities to develop a sustainable community-based system.
Patients are unable to flow effectively and efficiently through the healthcare system, as there is an increasing challenge to discharge patients who no longer require hospital care. Patients, families, health service providers in the hospital and in the community, need to collaborate and provide for best practices in reducing ALC volumes while ensuring the right level of care is delivered in the right place. It is essential for all stakeholders to be involved in developing a modern network for success (Appendix A). Recognition of culturally specific needs for our diverse population will allow for improved stakeholder engagement and sustainability of local new initiatives.
Providing communities of practice for healthcare providers, support workers, and patients and their families will result in improved access and resource management. Pressure is growing on the Wynne government to tackle chronic overcrowding in Ontario’s hospitals. The government allocated $21 million this year to “short-term transition care models,”20 however, the healthcare system needs to undergo a broad transformation to meet the care needs of the aging population.
1. Presentation at hospital – Innovation Through Risk Identification and Early Intervention21
Using standardized risk screening and assessment tools will allow for early identification of individuals in the ER at high risk for “failure to cope” or a “medically unnecessary” admission.21 When an individual is identified at high risk for ALC admission, early intervention of community supports and services can be initialized to prevent unnecessary hospitalization.21 Team-based resources including patient navigators should be available in each ER to inform and support clients, families, and caregivers thus allowing for informed choices.21 The benefits of this method are that it is standardized, and thus, there will be clear roles and expectations with enhanced coordination between hospitals and community.21 Early identification and comprehensive service planning will reduce ER visits and hospital admissions.21 The risks of a targeted approach to ALC, is the costs incurred of extending hospital staff hours and the challenges in triaging and directing to the ideal location due to capacity issues.21
2. System Access and Smooth Transitions of Care
To expand the community capacity, it is essential to assess the adequacy of various funding models. Scenarios considered would be ones that increased the availability of housing by using retirements homes or supportive housing respite beds to offer heightened care for ALC patients with low to medium care needs.21 Optimal utilization of the resources that fund short-stay respite beds in addition to maximizing the use of convalescent care beds in LTC homes, will support early hospital discharge.21 Another scenario is renovating LTC homes to increase acceptability and provide for preferred choice by patients.21 Implementation of the above scenarios will reduce ALC beds, allowing for a range of placement options appropriate to levels of care needs and equitable access to LTC homes.21 The risks of implementing this include the financial implementation costs, infrastructure costs and an increased demand for community services. 21
3. Community Capacity and In-Home Care21
Extending service maximums set by Ontario for nursing, homemaking services, personal support workers, occupational therapy, and physiotherapy will keep clients in the community.21 Increasing community support services for in-home personal support, homemaking, and caregiver respite, while simultaneously enhancing community supports and alternatives to LTC placement will allow for coordinated care across hospitals and community.21 These strategies will divert hospital ER admissions, allow for early detection, and for a rapid supportive intervention.21 The risks of this strategy include the cost of implementation and the lack of health human resources.21
4. ALC System Monitoring and Evaluation21
Collecting and tracking ALC data and analytics, will allow for evidence-based decision making, local analysis, planning and performance on a monthly basis.21 Conducting research to determine the percentage of hospitalized patients waiting for LTC placement and how individuals are placed, would create a standardized database across all sites.21 This database will support quality of care and allow stakeholder feedback to allow for best practice. 21 The risks of this initiative include the following: time and the cost to build an information system, and buy-in from all stakeholders. 21
5. Strategic Distributive Innovation
Recognition of the increased role for patients and family caregivers in the care process as well as the importance of supportive efforts that improve the social determinants of health and healthy living, will help allow for strategic innovation of a modern vision for healthcare.22 The government, health professionals, academics, the public and healthcare managers must use modern, collaborative approaches to improve the way change is made to the healthcare system.22 Strategic innovation must be considered providing for close to home care as well as matching health care resources and patient need, to meet the care needs of the aging population.
CONCLUSION & RECOMMENDATIONS
ALC is a significant barrier to effective use of costly hospital care. The considerations in this report are aimed at creating a plan to meet ongoing identification and management of the issue. Reducing ALC will allow for an increase the number of acute hospitalizations. The three presented dimensions of the ALC issue intersect and are pressing public health policy challenges that will impact the MOHLTC. Any solution must acknowledge the unique role and the limited capacity of our acute care hospitals. Identifiable improvements with investments will include risk identification and early intervention upon presentation to hospital, a comprehensive patient-focused system, smooth transitions of care, information technology, and in-home care. In addition, ALC system monitoring, and program evaluation are actionable on-going considerations that should be should be utilized to address systemic problems that cause or contribute to Ontario’s ALC challenge.