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

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Last updated: August 13, 2019

SUMMARYAn alternate level of care(ALC) patient is a designation made by a physician to describe a patient whooccupies a hospital bed but does not require the intensity of resources or servicesprovided in an acute care setting. ALC patients result in an inefficient use ofhospital resources.1 The bottleneck caused by ALC patients creates ahealth system level problem by affecting a hospital’s ability to care foracutely ill patients.2 Any solution to an excess of ALC patients mustrecognize the unique role and the restricted capacity of acute care hospitals.Reducing inpatient ALC will increase acute care hospitalizations for the same totalnumber of beds.3ISSUEALC is one of the most pressingpublic health issues in Ontario.

ALC and its effect on hospital bed occupancyrates 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 ALCissue that are most critical to address include increased community capacity tocare for people outside of the hospital setting, Emergency Room (ER) wait timesand the aging population. ALC is a long-standing, multifaceted, system-wideissue with severe implications for healthcare in Ontario. BACKGROUND & CURRENTSTATUSHistorically, ALC has beenidentified as a hospital problem. It has become increasingly evident that it isa system issue that cannot be resolved by hospitals alone.4Beginning in 2009, all hospitals in Ontario were expected to designate patientsas ALC according to the provincial ALC patient definition.

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5 ALC is acontinuously monitored metric to assess how well the health system and itspartners in acute and community-based care are working to provide seamless carefor residents.6 A lower rate is better, which is currently not thecase.The challengescharacterized by this issue in hospitals relate to the following issues andobservations: overcrowding, patient flow, access, integration, capacity, andresources.7 The inappropriate placement of non-acute patients inacute care beds results in a ripple effect causing decreased access to acutecare, cancellation of elective surgery and excessive ER wait times forinpatient beds for acutely unwell patients. 8 ALC is a complex,serious system issue, which impacts patients access to acute care, patientsafety, and patient quality of life.

9 Most ALC patients are over 75years of age.5 ALC has a negative effect on the health andwell-being of a patient and their families and is very costly to the healthcaresystem. Increased Community CareCapacity to Care for People Outside the HospitalALC is typically seen for patientswaiting for placement primarily in long-term care (LTC), in addition to chroniccare, rehabilitation and convalescent care facilities, and in-home careprograms.10 The lack of placement options that meet the requirementsof ALC patients outside the hospital is the main reason why ALC patients arenot discharged from the hospital when they no longer need acute care.

Overcrowdingin 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 highas 140% while the international standard for safe occupancy is 85%.11 Over the past two years, thenumber of patients waiting as inpatients for ALC has increased 16%.12There are approximately 4,500 patients waiting to receive care in a moreappropriate setting, and more than half of them are waiting for LTC.13The average hospitalized patient in need of LTC spends 68 days waiting.13Ontario’s Auditor General Bonnie Lysyk found that more than 4,100 of Ontario’s31,000 beds are being occupied unnecessarily by patients waiting for LTC orhome care.14 While hospitalized, it is common for ALC patients toexperience a decline in their overall health and well-being.8 TheOntario Hospital Association (OHA) blames the acute-care overcrowding on ashortage of available LTC and home care.

15Emergency DepartmentTimesThe OHA stated that 90% ofpatients in the ER wait 37 hours or less for hospital beds, and 23 hours orless for intensive care beds.14 Acute care areas are being re-purposedas holding areas for ALC patient. Acute care patients cannot be admitted andthe consequences of this are congested ERs with long wait times, crowded wards,and delayed or canceled procedures.

1,16 If fewer hospital beds wereoccupied by ALC patients, they could be used immediately for admitted patientsfrom the ER, thus decreasing overcrowding. ER wait times “are a criticalbarometer for how the healthcare system is functioning and the warning alarm issounding loudly.”11Some patients may chooseto stay in a convenient and safe acute care hospital rather than move to a lessdesirable LTC facility. The OHA has been working with the MOHLTC to find anddevelop innovative solutions that address this issue.

12 Theseefforts are aimed at alleviating the health system pressures related to ER andALC, improving wait time and enhancing overall access to care.5Recently, it was announcedthat there will be an additional 1,200 acute care hospital beds available inOntario in preparation for a surge in demand due to the flu season.18This 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 thehealthcare system and hospitals.15Aging PopulationOne of the most pressingpolicy mandates of our time is Canada’s aging population, which is growing quickly.

Individuals are living longer with frailty and more complex medical needs.12As a result, the ALC population is expected to grow considerably.4 TheOHA notes that the number of annual visits to the ER is likely to increase by30% over the next 25 years.

13 Most ALC patients are over the age of75, this demographic is expected to grow by a staggering 32% over the next 10years.5 By 2021, over 130,000 LTC home beds would be required if demandcontinues to grow at this rate in the future.1 The MOHLTC has made importantstrides in implementing programs to address the ALC challenge, however, thereare still further opportunities to develop a sustainable community-basedsystem. CONSIDERATIONSPatients are unable toflow effectively and efficiently through the healthcare system, as there is anincreasing 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 whileensuring the right level of care is delivered in the right place. It isessential for all stakeholders to be involved in developing a modern networkfor success (Appendix A).

Recognition of culturally specific needs for ourdiverse population will allow for improved stakeholder engagement andsustainability of local new initiatives. 

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