SUMMARY flow, access, integration, capacity, and resources.7 The


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.

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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.


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

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

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

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

Aging Population

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


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. 


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