alternate level of care systems issues and recommendations

Alternate Level of Care Systems Issues and RecommendationsReport prepared by the Central East LHIN ALC Task Group

For more information, please contact:Central East LHIN905-427-54971-866-804-5446www.centraleastlhin.on.cacentraleast@lhins.on.ca

Alternate Level of Care Systems Issues and Recommendations June 2008

Right Care, Right Place, Right Time i

“The significant problems we face cannot be solved at the same level of thinking we were at when we created them.”

Albert Einstein


Right Care, Right Place, Right Time ii

Acknowledgements This report is the result of many hours of collaborative effort. We would like to acknowledge and thank

the individuals and organizations that have contributed to the development of this report. The ALC Task Group Members Sheila Neuburger: Chair Glyn Boatswain: Vice-Chair Vice-President Clinical Services Patient Flow Manager Whitby Mental Health Centre Rouge Valley Health System

Janet Burn, Program Director Candace Chartier, Chief Executive Officer Northumberland Hills Hospital Omni Healthcare Ltd.

Sharon Chapman-Sheehan, Regional Manager Lesreen Romain, Executive Director Central East CCAC Victorian Order of Nurses- Toronto York

Marshall Elliot, Executive Director Carol Smith Romeril, CNE/Vice-President Community Living Kawartha Lakes Ross Memorial Hospital

Melanie Flood, Manager of Clinical Support Services Diane Southwell, Discharge Planner Haliburton Highlands Hospital Campbellford Memorial Hospital

Carol Gordon, Chief Executive Officer Karen Southwell, Leader Program Support Kawartha Participation Projects Lakeridge Health Corporation

Craig McCleary, Branch Manager Joni Wilson, Assistant Director Resident Care Canadian Red Cross Community Health Services St. Joseph’s at Fleming

Shailesh Nadkarni, Program Director Nancy Veloso, Manager of Social Work Dept Peterborough Regional Health Centre The Scarborough Hospital

Andrew Marsden, Business & Performance Analyst Brian Laundry, Senior Integration Consultant Central East LHIN Central East LHIN

Patti Reed, Consultant The Distance Learning Group

The ALC Task Group would like to extend a thank you to each of the external community members for their insights and advice on the recommendations found in this report.


Right Care, Right Place, Right Time iii

Foreword Hospitals in the Central East Local Health Integration Network (Central East LHIN) are struggling to

manage the growing pressures with regard to alternate level of care (ALC) patients. “ALC” patients refers to those people in hospital who are no longer in the acute phase of their illness but still occupy an acute care bed while waiting for another more appropriate “alternate” type of service. The ALC occupancy rate

for non-acute patients in acute care beds in Central East LHIN hospitals is about 18% and equates to

over 165 hospital beds, and this number is steadily growing. Over half of these ALC patients are waiting to move to a long-term care home. But long-term care homes in the Central East LHIN are at 98.9% occupancy

– in other words, it appears for these patients there is nowhere to go! In an effort to truly understand the ALC impact in the Central East LHIN, the ALC Task Group has spent

the past year reviewing the limited available data, reading related reports to ascertain best practices, incorporating information available from the Ministry of Health and Long-Term Care, initiating their own hospital ALC survey and pilot study, and developing a patient process flow map to identify the barriers and

issues most relevant to their experiences in the field. What they found is that hospitals throughout the Central East LHIN have tried a range of innovative

approaches to reduce the number of ALC days with varying degrees of success. Although “ALC” has historically been identified as a hospital problem, it has become increasingly clear that this is a system issue that cannot be resolved by hospitals trying to manage alone. Improvements to patient flow practices

and hospital efficiency are critical and can still be found to varying degrees, but this focus is no longer enough.

It is for this reason that despite the best efforts of the ALC Task Group to stay within the original scope of acute care only, it was agreed that it could not fulfill its mandate without including specific recommendations across the continuum of care.

As a result, the recommendations for action in this report are not limited to in-hospital “fixes”. This is an issue of vital importance to anyone, especially seniors, who may find themselves requiring acute health

care. Successfully implementing the recommendations in this report will require both a philosophical shift in thinking about how we care for a rapidly aging population and a significant system-level commitment from health providers.

Patients, families, health service providers in the hospital and in the community are challenged to act

together and to share responsibility for reducing the ALC volumes by 10% per year while ensuring

the right level of care is delivered in the right place and at the right time with the right resources to the residents of the Central East LHIN.

In and of itself, this report and the recommendations contained herein are not enough. They represent the first steps in a long journey that requires commitment, collaboration and persistence. There is willingness and an opportunity to move forward in addressing ALC pressures and this ALC Task Group report

proposes both independent and systemic solutions in taking the first steps on the long road to recovery. The time for action is now.


Right Care, Right Place, Right Time iv

Table of Contents Acknowledgements ii Forward iii Executive Summary 1 Background 5 Project Charter 6 Purpose 6 Vision and Values 7 Mandate 8 Information-Gathering Process 10

1. Group Deliberations 10 2. Literature Review 10 3. Data Collection 11 4. ALC Snapshot Survey 11 5. Hospital Pilot Study 12 6. Hospital ALC Patient Flow Process Map 12 7. Ministry Policy Review 12 8. Regional Consultation 13

Summary of Findings 14 Demographics 14

Hospitals in Central East LHIN 14 What does the ALC data look like in the Central East LHIN Hospitals? 15 ALC Snapshot Survey 18

Hospital Pilot Study 19 Ontario Hospital Association (OHA) ALC Snapshot Survey 20

Case Mix Grouping for ALC Designated Patients 21 Long-Term Care and the Role of the Community Care Access Centre 23 GTA Rehab Network Survey 24 Hospital patient flow process map 24 ALC Discharge to Appropriate Discharge Referral Destination 26 Overview of the ALC Challenges in Central East LHIN 27

Challenges 27 1. Patient-centred care 27 2. Risk identification 28 3. Definition of ALC and ALC Data Collection 29 4. Capacity of Community Services to enhance patient flow 29 5. Long term care home placement 30 6. Specialized Services 30 7. Ministry Policy Review 30


Right Care, Right Place, Right Time v

Opportunities and New Initiatives 32 The Flo Collaborative 33

Home at Last 33 Geriatric Emergency Management (GEM) Nursing 33 Timely Discharge Information System Demonstration Project 33 Toronto Balance of Care Research Project 34 Increased Scope of Practice for Registered and Non-Registered Staff 34 Central East LHIN Aging at Home Strategy 34 Recommendations 35

1. Presentation at Hospital Risk Identification and Early Intervention 35

2. Patient Flow and Communication in Hospital Acute and Post-Acute Care 38

3. System Access and Smooth Transitions Across Continuum of Care ALC Discharge and Referral Destination and Patient Flow 40

4. Community Capacity and In-Home Care 42 5. Health Human Resources 43 6. ALC System Monitoring and Evaluation 44

Summary 46 Implementation Action Plan 47 References 51 Appendices 53 Appendix 1: Central East LHIN Task Group Terms of Reference 54 Appendix 2: Central East LHIN Task Group Project Charter 56 Appendix 3: Table 3 – Central East LHIN Hospital Discharge Destination 63 Appendix 4: Central East LHIN Planning Zone Profiles 64 List of Tables and Figures Table 1: Summary of Alternate Level of Care Data for Central East LHIN Hospital Sites 16 Table 2: ALC Task Group Snapshot Survey 19 Table 3: Top Case Mix Groupings for All ALC Cases 22

Figure 1: ALC Patient Care Continuum 8 Figure 2: Per Cent of ALC Patient Days Categorized by Discharge Destination 17 Figure 3: Patient Flow Process Map 25 Figure 4: ALC Trajectory 32


Right Care, Right Place, Right Time 1

Executive Summary Alternate Level of Care (ALC) is a complex, serious system issue that impacts patient access to care, patient

safety, and patient quality of life. It is costly to the health and well-being of the patient and their loved ones, and it is costly to the health care system.

All across Ontario, people are waiting for days and weeks to receive appropriate levels of health care. In hospital, the patients waiting for an appropriate level of care to meet their needs are termed “ALC” by the health care system. ALC is a designation made by an attending physician or authorized hospital designate

to describe patients who are no longer in the acute phase of their illness but still remain in the hospital in an acute care bed while they are waiting for another, or alternate, level of care. ALC patients may be waiting for a transfer to a chronic care facility, a rehabilitation facility, a convalescent care facility, a long-term care

home or an in-home care program. The ALC occupancy rate in acute care beds in Central East LHIN hospitals is about 18% and is equivalent to

over 165 hospital beds being used by patients who do not require acute care but cannot be safely discharged. The majority of these patients (over 40%) are people eighty years of age waiting for placement in a long term care home.

Long-Term Care Homes (LTCHs) in Central East LHIN are at 98.9% occupancy. Simply building more long-term care homes to resolve the ALC pressures is NOT a viable option – it is not financially viable for the

healthcare system, and perhaps more importantly, it is not viable as the only solution to meet the appropriate level of care needs for those who no longer require acute hospital care. In several situations, there are more appropriate locations for people to receive care other than in the hospital or a long-term care home. The ALC

Task Group envisions a healthcare system where the first choice “default” option is supporting a person to go home from hospital with the required supports in place, whenever possible.

This Report prepared by the Central East LHIN ALC Task Group reviews a summary of the findings over the past year, provides an overview of the main ALC challenges in the Central East LHIN, and offers highlights on exciting opportunities and new initiatives that will help address the ALC dilemma.

Based on the analytical discussions, qualitative and quantitative data collection, review of provincial and other reports, and feedback from the community consultation processes, the Central East LHIN ALC Task

Group created 52 recommendations. Even in the face of an increasing trend, these recommendations have the potential to reduce the ALC volumes by 10% per year while pursuing the vision of “Right Care, Right Place, Right Time” for the residents of the Central East LHIN.

Although the ALC Task Group was mandated to address internal patient flow processes within hospitals, it was found that coordinated care across hospital and community services is critical to ensure people

are in the “right bed” at the right time. As a result, the ALC Task Group recommendations represent a comprehensive system-approach to addressing the ALC issues through the early identification and prevention of avoidable hospitalizations, improved hospital and patient flow processes and timely

discharge practices, and increased community capacity to care for people in their own homes.



The recommendations are organized into the following six overall themes: 1. Risk Identification and Early Intervention

• Recommendations focus on identifying and supporting clients and their families/caregivers that are at high-risk of becoming designated as an ALC patient; through early intervention and

coordinated linkages with Community Care Access Centre (CCAC) and community support services and in encouraging families and health care teams to create patient-centred individual advance planning for the future needs, it is anticipated that there will be fewer people

designated ALC and less ALC days. 2. Patient Flow and Communication

• Recommendations pertain to improving patient flow practices and communication within the hospital and to objectively planning appropriate discharge to meet patient care needs.

3. System Access and Smooth Transitions across Continuum of Care

• Recommendations specific to managing the ALC patient flow out of the acute care hospital setting to an appropriate level of care in collaboration with various referral destinations

(e.g. home with community services, supportive housing, rehabilitation, complex continuing care, mental health, long-term care home) to reduce the average length of stay.

4. Community Capacity and In-Home Care • Recommendations that speak to the need to provide care in the community so that people may

remain independent in their own home for as long as possible and thereby avoid inappropriate

visits to the emergency department or hospital admissions and reduce the number of days people stay in acute care but no longer require that level of care.

5. Health Human Resources

• In order to implement the majority of the recommendations made by the ALC Task Group, there are significant health human resource implications. Recommendations pertain to staff training,

recruitment and retention to achieve success in reducing the number of people designated as ALC as well as reduce their length of stay.

6. ALC System Monitoring and Evaluation

• In the preparation of this report, the ALC Task Group found it difficult to find reliable statistical information related to ALC due to inconsistent data collection and the interpretation of what

ALC means. Recommendations support the need to standardize a definition, to provide education to those collecting/using the information to facilitate improved data quality and to implement a standardized reporting mechanism to monitor the effectiveness the recommended

changes are having on making system improvements.



All of the recommendations are considered to be essential in addressing the continually growing ALC problem in Central East LHIN over the next three to five years. However, the ALC Task Group identified

12 recommendations that can be implemented locally and are anticipated to have the highest potential impact on ALC over the next one to two years when implemented, and one further recommendation that must be addressed provincially to enable the work of the ALC Task Group.

The local priority recommendations are listed below:

1. Utilize standardized risk screening and assessment tools for the early identification of people in emergency department at high-risk for “failure to cope” or “medically unnecessary” admission; and when a person is identified at high-risk, facilitate the early intervention of community supports and

services to prevent hospitalization.

2. Provide specialized staff resources in each hospital Emergency Department (days and evenings

7 days/week) to inform and support clients, families and caregivers with regard to their options; including what community supports are available and how to access them.

3. Create and implement a Central East LHIN standard policy framework for the management of ALC issues.

4. Expand definition and recognition of ALC beyond acute care bed spaces to include all patients waiting in post-acute beds for an alternate level of care.

5. Provide in-hospital activation/exercise program to maintain optimal functionality and mental wellness while in hospital and continue program while waiting for alternate level of care placement.

6. Review the capacity of various funding models to increase the availability of housing by using retirement homes and/or supportive housing respite beds to offer enhanced care for ALC patients with light to medium level of care needs.

7. Provide training and financial resources to encourage specialization to create Behavioural Support

Unit(s) within LTCHs that include short-stay transitional beds for people with temporary cognitive

decline and permanent beds for people with ongoing behavioural management needs. 8. Develop an enhanced/comprehensive community services discharge planning process for acute

patients screened at high risk that begins upon admission (or earlier) in order to avoid/delay anticipated decline.

9. Increase community support services for in-home personal support, homemaking and caregiver respite.

10. Develop a Health Human Resource Strategy including professional education as a critical enabler for all of the ALC Task Group recommendations.



11. Central East LHIN to undertake a Research Study to determine the percentage of hospital patients waiting for a LTCH placement that could potentially receive the most appropriate level of care

in-home if enhanced community supports were available and affordable.

12. Create a Central East LHIN Alternate Level of Care Implementation Committee to initiate, oversee

and monitor implementation of the approved recommendations, to track data for planning purposes and to support evidence-based decisions on where to invest resources for the most impact.

The Ontario Ministry of Health and Long-Term Care (MOHLTC) provincial regulations determine the number of funded service hours that the Community Care Access Centre (CCAC) may provide for an individual in their home. With earlier intervention of in-home supports in the community it is expected that there will be

less emergency visits and avoidable hospitalizations; and with extended supports after hospital discharge it is anticipated that placement in a Long-Term Care Home may be delayed or avoided.

Therefore, it is recommended that MOHLTC: 1. Extend CCAC service maximums set by provincial regulations for nursing, home-making services

and enhanced personal support and the capacity for occupational therapy and physiotherapy to

keep clients in community as long as possible and to delay LTCH placement. The above recommendations made by the ALC Task Group cannot be implemented by the hospitals alone

if they are to be successful. The ALC Task Group has proposed an Implementation Action Plan that shares system-wide responsibility for addressing the ALC issues in the Central East LHIN. In conjunction with the Central East LHIN and the MOHLTC policy-makers, local leadership is required from people across the

hospital and community health care sector who are committed to working collaboratively to reduce ALC days, improve patient flow and support patient choice in the most appropriate and cost-effective setting so that patients can access the right service at the right time to regain their health.

The ALC issues will not be resolved overnight, nor will this report be the final word. The ALC Task Group fully supports and endorses the findings and recommendations in this report and is committed to working

together to support their implementation as soon as possible.



Background All across Ontario, people are waiting for days and weeks to receive appropriate levels of health care.

They are waiting in the ambulance to be admitted to an emergency bed, they are waiting in the emergency department to be admitted to acute care in hospital, they are waiting in the hospital to go home with community supports or to be placed in a long term care or retirement home, they are waiting for a

rehabilitation or convalescent bed, or they are in a long-term care home waiting to be transferred to a different home closer to their family. (See below: Mr. Smith’s story.)

In hospital, the patients waiting for an appropriate level of care to meet their needs are termed “ALC” by the health care system. “Alternate Level of Care” or ALC is a designation made by an attending physician or authorized hospital designate to describe patients who are no longer in the acute phase of their illness

but still remain in the hospital in an acute care bed while they are waiting for another, or alternate, and more appropriate level of care to meet their needs. ALC patients may be waiting for a transfer to a chronic care facility, a rehabilitation facility, a convalescent care facility, a long-term care home, supportive housing

or retirement home, or an in-home care program. There are many reasons why people are “stuck” waiting for another type of service and are blocked from

movement through the current health care service system. Some of the reasons include: the unavailability of family to support discharge; the lack of community service capacity to meet the growing demand; the lack of coordination between providers and levels of care; or not enough trained health care professionals in

non-acute settings to provide the specialized care required for people with complex needs (e.g. cognitive or behavioural issues).

Mr. Smith’s Story Mr. Smith is an 85 year old married man who was admitted to hospital after having been found unresponsive on the floor by his

family. With multiple medical complications including diabetes, dementia and Parkinson’s disease, Mr. Smith required an acute

care admission. Due to the high demand for acute care beds, Mr. Smith spent two days in the Emergency Department.

While waiting for an admission he became weaker, unable to walk and quite confused. There was no geriatric assessment or

social work support available in the ER. Once admitted to the unit, Mr. Smith appeared quite agitated and his family voiced their

concerns about his significant behaviour change. Mr. Smith spent a few days in acute care while his blood sugars were stabilized

and a discharge date was set. Mr. Smith’s family reported that they could not cope with Mr. Smith’s current functional and

cognitive state at home and so Mr. Smith was designated “ALC”, waiting in hospital for alternate discharge arrangements.

The social work and physiotherapy team recommended rehabilitation but his application was declined due to his poor cognitive

status. Alternate discharge options were explored but Mr. Smith’s family again stated they did not have the financial resources or

ability to cope with him at home. Long term care placement was reviewed and reluctantly agreed to by Mr. Smith’s family.

Long-term care homes in Mr. Smith’s local community were not available so after 2 months in which he further declined, he

moved to a long term care facility in the next town.



ALC is a complex, serious system issue that impacts patient access to care, patient safety, and patient quality of life. It is costly to the health and well-

being of the patient and their loved ones, and it is costly to the health care system. As the population ages, this pressure will continue to grow until ways are found to improve patient flow and system capacity. Strategies must

be found that will prevent avoidable hospital admissions and that will facilitate timely discharge from acute care to appropriate supported care settings in the community.

Project Charter As a result of an extensive community engagement process, the Central East Local Health Integration Network (Central East LHIN) identified the regional issues of accessibility and wait times as a priority in their Integrated Health Service Plan (November 2006). Of particular concern was the high number of

alternate level of care or ALC patients waiting in hospital and the immediate need to enhance patient flow across the continuum of care.

The ALC project was initiated through the Central East Executive Council (CEEC); a hospital, CCAC and Central East LHIN CEO group that is particularly concerned about patient flow issues in various parts of the health care system. In response to the CEEC and in order to more fully understand the current ALC

challenges in the region, in May 2007 the Central East LHIN invited key stakeholders to form an ALC Task Group. This multi-stakeholder Task Group was asked to objectively examine the ALC issues to gain a comprehensive understanding of their system impact specific to Central East, and to provide advice to the

Central East LHIN through the subsequent development of practical recommendations for short-term and long-term strategies to alleviate the ALC pressures identified. The overall purpose of the ALC Task Group recommendations is to achieve better health outcomes for patients who are waiting for alternate levels of

care while in acute care hospitals. Purpose The Central East LHIN ALC Task Group is a collaboration of sixteen organizations involved in providing health care in the home, in the hospital, in long-term care, and in sub-acute care settings and community

care settings. The ALC Task Group membership includes hospitals (general and tertiary), CCAC, long-term care homes and community support services. The Project was driven by several components including:

a. a desire to provide excellent care to all patients and prospective patients within the Central East

LHIN geographic area; b. the need to identify best practices to guide care for the ALC patient group; c. health economics; and

d. the need to understand and improve patient flow issues within the Central East LHIN.

“Without question, the single biggest challenge facing Ontario’s hospitals today is the significant increase in the number of alternate level of care (ALC) patients waiting in hospitals who would be better cared for in other parts of our health care system… Now almost 20% of acute care hospital beds are filled with ALC patients, almost 30% of medical beds!”

Tom Closson, CEO Ontario Hospital Association

(2/22/08 OHA eBulletin)



ALC Task Group Vision Statement:

Right Care, Right Place, Right Time We envision a proactive system approach to ensure

client/patient access to the right level of care at the right

time and the right place with the right resources.

The overall purpose of the ALC Task Group recommendations is to achieve better outcomes for patients who are waiting for alternate levels of care while in acute care hospitals. Better outcomes include:

more timely moves to appropriate levels of care and fewer days waiting in an acute care hospital setting,

home with appropriate levels of support following an acute care admission and avoiding

ALC designation, earlier assessment of long term care needs and earlier involvement of patient and family in

discharge planning, and

enhanced community supports so that people may live in their own homes for longer periods. Vision and Values There is a stigma attached to “being ALC”. Patients who are waiting for an alternate level of care provide daily reminders of some of the inefficiencies in the hospital system and may be blamed for “taking up” an

acute care bed, thus limiting access for “someone who really needs it”. Terms such as “bed-blockers” and “ALC case” or “ALC bed” are often used, and providing care for these patients is sometimes viewed as low-status and unchallenging by registered nurses and rehabilitation staff.

Embedded in the work of the Central East LHIN ALC Task Group is the principal value of respect and delivery of the best quality care for the person and their family. Conscious effort has been made to talk about

people and patients, both in the Task Group deliberations and throughout this report. The Central East LHIN espouses the same values as the Ontario Health Quality Council. It envisions a health

care system from a population health perspective that is safe, effective, person-centred, accessible, efficient, equitable, integrated, and appropriately resourced.

The ALC Task Group holds similar values for sustaining the level of care a person needs to get well and remain safe and healthy. A person-centred approach dictates consideration of care in the home or community as the first choice for care. The ALC Task Group worked with the following vision in the

development of their recommendations:



Mandate The ALC Task Group was mandated to:

i. Conduct an environmental scan of Central East LHIN ALC pressures and existing practices, and ii. Prepare a Central East ALC Action Plan that includes recommendations and performance goals.1

The ALC patient is defined by the Canadian Institute for Health Information (CIHI) as: “An ALC patient has finished the acute care phase of his/her treatment but remains in the acute care bed”.2

Currently, CIHI only collects information for the acute hospital patient ALC population as defined above. Using this definition and available data, the ALC Task Group concentrated their efforts on the internal

processes within hospitals as well as their interfaces with relevant community processes and supports both pre-admission and post-hospital discharge. An analysis and recommendations directly related to long-term care, supportive housing, and home care capacity was considered out of scope for this working group. However, coordinated care across hospital and community services (including long-term care) is critical to ensure people are in the “right bed” at the right

time. As a result, the scope of work of the ALC Task Group broadened slightly to include the patient’s journey preceding the designation to ALC in an acute care bed in hospital (and recommendations for potential prevention opportunities) to the challenges associated with discharge to an appropriate care

destination out of an acute care bed in hospital (and recommendations for potential service enhancement opportunities), in addition to the original mandate of determining the underlying causes and contributing factors to the ALC pressures in the Central East LHIN.

Figure 1: ALC Patient Care Continuum In Figure 1 (above) Acute indicates presentation at the hospital and acute care admission and inpatient stay. Non-Acute indicates the point at which the physician determines that the patient no longer requires acute care and designates the patient with Alternate Level of Care needs. This is the start of the hospital stay as

1 See Appendix 1 for the ALC Task Group Terms of Reference.

2 Canadian Institute for Health Information Discharge Abstract Database, April 2006.



an ALC case/patient. ALC days are tracked separately as part of the acute care length of stay. It is this non-acute stage on the care continuum that was the original scope of the ALC Task Group.

When the patient is “ALC Discharge Ready” it is the point at which referral to an appropriate destination for alternate care has been processed (eligibility and applications completed, referral accepted), the

destination is ready to receive the patient (available bed/space) and the patient is ready for discharge from the hospital. It is important to note that a patient may be ready for discharge to an appropriate destination but if the service/supports are not immediately available, then he/she must wait to access

it, resulting in an ALC designation. Community and Non-ALC Hospital Resources indicates discharge to an alternate level of care

(e.g. home, home with supports, supportive housing, long-term care home, rehabilitation, palliative care) as identified in the patient’s discharge plan.



Information-Gathering Process The ALC Task Group underwent an exhaustive information-gathering process to inform the

final recommendations. 1. Group Deliberations

The ALC Task Group met over twenty times from June 2007 to June 2008. Meetings were held

at Whitby Mental Health Centre, Ross Memorial Hospital and Rouge Valley Health System in-person and utilizing video-conferencing. In addition, Task Group members were assigned specific project tasks to complete between meetings and asked to report back to the whole

group for discussion. The Central East LHIN set up a private website to post all meeting agendas, meeting notes, and reference materials. Members also attended a two-day introductory course on Project Management in August 2007 in which they developed the Project Charter.

Several presentations were made to the ALC Task Group including:

• STRATA Health Solutions – July 2007

Daniela Catallo • Patient Flo Collaborative Initiative – July 2007

Erin Gilbart - MOHLTC

• Seamless Care for Seniors Network – November 2007 Dr. Peto

• Peterborough Flo Team – February 2008

Carol Howson • Emergency Task Group draft report – April 2008

2. Literature Review

There has been considerable study, review and knowledge exchange around the issues that contribute to the ALC dilemma. In recent years there have been several ALC studies conducted

across the province and the country to identify the key factors contributing to ALC patients waiting for the care that they need.

Two of the seminal documents that were most relevant to the work of the ALC Task Group were: the MOHLTC Appropriate level of care: a patient flow, system integration and capacity

solution Report by the Expert Panel on Alternate Level of Care (December 2006) and Alternate

Level of Care-Challenges and Opportunities, a collaborative position paper by the Ontario Association of Community Care Access Centres, the Ontario Association of Non-Profit Homes and Services for Seniors, the Ontario Hospital Association, and the Ontario Long-Term Care

Association (May 2006).



Common recommended strategies to address the ALC challenges identified in both of these reports include:

• Support independence through increased community-based comprehensive care • Improve the coordination of services and support multi-stakeholder collaboration

to promote efficiencies in patient flow

• Review hospital discharge policies and practices to Long-Term Care Homes and establish standard requirements

• Develop education and awareness programs to inform patients, families and providers

about ALC designation, levels of care and the value of planning for future care needs

In addition to these reports, the ALC Task Group reviewed the key findings and

recommendations from several other national, provincial and regional reports relevant to ALC, emergency care, acute care, rehabilitation, wait times and access.3

3. Data Collection

To conduct the environmental scan, the ALC Task Group gathered information from several data sources including:

• demographic data (e.g. total population, age breakdown, population growth, low-income, cultural diversity, psychogeriatric population growth estimates) provided by the Central East LHIN

• standardized hospital data review for each acute care facility (e.g. top 15 Case Mix Groupings and top 15 diagnoses for ALC cases, the average length of stay in an ALC bed, the percentage of ALC days as a total of all hospital days, age divisions for

ALC cases, discharge destination summary) extracted from the CIHI Discharge Abstract Database (DAD)

• community capacity information (e.g. the number of long term care homes, total

number of beds and vacancies, CCAC wait lists for placement) provided by the Central East CCAC

• MOHLTC Inpatient Discharges data extracted from the Provincial Health

Planning Database

4. ALC Snapshot Survey

In the summer of 2007, the ALC Task Group conducted a survey of the Central East LHIN hospitals to determine the status of their ALC patients by asking the question, “What are ALC patients waiting for?” in an effort to better understand where strategic investments should be

made in the Central East LHIN to have the highest impact. As a result of the survey, the ALC Task Group realized that a significant number of people

were remaining in acute beds in hospital due to either the lack of available service to meet their level of care need (e.g. long waiting lists for assisted living accommodation) and/or the lack of affordability (e.g. patient can only afford LTCH basic accommodation which has very

limited vacancies).

3 Please see a full list of References at the end of this report.



5. Hospital Pilot Study

Once the Snapshot Survey was completed, the ALC Task Group realized that what people were

waiting for was not necessarily the most appropriate discharge destination. This lead the ALC Task Group to ask the key question, “What alternate level of care is actually needed?” regardless of service availability or affordability. In an effort to answer this question a working group

developed a qualitative pilot study among several hospitals in the Central East LHIN utilizing an individual patient assessment instrument. Due to the lack of resources (time and people) to fully implement the study, it was not wholly completed although the observations made during the

study have been used to further inform the recommendations in this report.

6. Hospital ALC Patient Flow Process Map

The ALC Task Group developed a visual Patient Flow Process Map from the point of hospital admission to ALC designation to hospital discharge. A set of standard questions were developed for each transition juncture identified on the Process Map.

At the request of the ALC Task Group, every hospital within the boundaries of the Central East LHIN referred to the Patient Flow Process Map as a framework to conduct an internal

review of how they were managing their ALC patients. This ALC snapshot examined patient characteristics, patient flow and access issues, and was explicit about the barriers experienced at specified transition junctures within the hospital.

The barriers identified by each hospital were rolled up into a working document to form a current picture of the ALC challenge in Central East. This detailed information was used by the

ALC Task Group to search out evidence-based risk mitigation strategies from the literature and to develop solutions most applicable and relevant to the communities in Central East LHIN.

7. Ministry Policy Review

ALC Task Group members reviewed the impact of provincial regulation, policies and guidelines (e.g. Provincial Regulations re: Long Term Care Homes admission processes,

maximum allowable service hours of home support, crisis placements) on ALC patient flow and equitable access issues.



8. Regional Consultation

Once preliminary recommendations were drafted in March/April 2008, members of the ALC

Task Group attempted to meet with as many Central East LHIN planning partners as possible to present the findings and solicit feedback. The group was successful in obtaining feedback from the following planning partners:

• Durham East Collaborative • Durham North/Central Collaborative • City of Kawartha Lakes Collaborative

• Northumberland/Havelock Collaborative • Peterborough City and County Collaborative • Scarborough Agincourt Rouge Collaborative

• Scarborough Cliffs Centre Collaborative • Mental Health and Addictions Steering Committee • Seamless Care for Seniors Steering Committee

• Central East Executive Council • Chronic Disease Prevention and Management Steering Committee • Primary Care Working Group

• Emergency Department Task Group • Rehabilitation Task Group • E-Health Steering Committee

The feedback from the planning partner consultations was reviewed and incorporated into the final report.

The following sections include an analysis of the findings, the presenting challenges and series of recommendations.



Summary of Findings Demographics The Central East LHIN consists of the Durham Region, the City of Kawartha Lakes, the County of Haliburton, Northumberland County and Peterborough County and the eastern portion of the City of Toronto (formerly

called Scarborough). According to the 2001 Census, there were 180,000 seniors (65 years or older) including 99,208 over 75 years

of age, living within the Central East LHIN. Senior residents comprised 13% of the total population in the Central East LHIN with a projected rate of growth that is disproportionately higher (47.5%) than the rest of the population. The number of seniors is projected to increase to 265,000 people by 2016.

It is important to understand the demographics of the senior residents in our communities to fully understand the ALC challenge. Provincial hospital data shows that the population most affected by ALC is

the frail elderly (over 75 years of age) medical patient4. As people age, they are more at risk of developing multiple health issues. The frail elderly population represents 3% of the total Ontario population and use nearly 30% of provincial health care funding.

In addition to the high medical needs, social factors such as low income, isolation and language barriers may prevent people from accessing needed services and supports. In Central East LHIN the incidence of

low income ranges widely from 6.3% of the population in Durham North Central to 24.7% in Scarborough Cliffs-Centre. In the southern areas of the Central East LHIN, 24% of the Scarborough area population was new immigrants in 2001 and almost 12% of the Scarborough residents speak neither English nor French.

Elderly people may not have the personal resources (e.g. supportive family or friends to provide care) or financial resources to transition from the hospital to home quickly and therefore, spend more days designated as ALC patients.

Hospitals in Central East LHIN The Central East LHIN consists of nine community hospital corporations and 14 hospital sites, as well as

Whitby Mental Health Centre. A recent bed census by the Central East LHIN Emergency Department Task Group identified a total of 1,642 acute care beds. Some specialized health care services (such as specialized rehabilitation) are not performed within the Central East LHIN and residents must go out of area to access.

4 Ontario Inpatient Discharge Table, Provincial Health Planning Database 2006/07.



Hospitals and Locations: Lakeridge Health Corporation – Oshawa, Bowmanville, Port Perry, Whitby

Markham Stouffville Hospital – Uxbridge site only Peterborough Regional Health Centre - Peterborough Haliburton Highlands Health Services – Haliburton, Minden

Ross Memorial Hospital - Lindsay Northumberland Hills Hospital - Cobourg Campbellford Memorial Hospital - Campbellford

Rouge Valley Health System – Ajax/Pickering, Scarborough Centenary The Scarborough Hospital - Scarborough General, Scarborough Grace Whitby Mental Health Centre (WMHC) – Whitby

Note: The ALC data reviewed in this report does not include the WMHC as it was collected prior to the divestment of WMHC and it is a tertiary level psychiatric hospital. What does the ALC data look like in the Central East LHIN Hospitals? Several sources of data were used by the ALC Task Group to describe the alternate level of care patient population across the Central East LHIN. The ALC information was obtained from the Ontario Provincial

Health Planning Database and is primarily based on Canadian Institute for Health Information (CIHI) data. Table 1: Summary of Alternate Level of Care Data for Central East LHIN Hospital Sites, 2006/07 provides

an overview of the number of ALC patients and the average length of stay in comparison to the number of acute care patients and the average length of stay as a percentage of all hospital days for each site. This data is based on the 2006/07 fiscal year (April 1, 2006 to March 31, 2007) and identified the hospitals

that experienced both the highest number of ALC cases and the highest number of ALC patient days as the following:

Lakeridge Health Corporation: Oshawa Site = 892 cases, 11,007 ALC days

Peterborough Regional Health Centre = 321 cases, 9,586 ALC days The Scarborough Hospital: General Site = 324 cases, 6,332 ALC days

These three sites represented 44% of all ALC days (60,692) in the Central East LHIN. While the total number of ALC patients and number of ALC days is primarily a function of hospital size (these three hospitals represent 50% of all Central East LHIN sites), the average length of stay (ALOS5) per ALC patient is a

function of a variety of factors, including availability of non-hospital resources to provide care. The hospitals that experienced the most severe ALC pressure with the longest average length of stay during

the same 2006/07 period were: Campbellford Memorial Hospital = 67 days ALOS (40.7% of total days in site) Haliburton Highlands Health Services = 33.3 days ALOS

Peterborough Regional Centre = 29.9 days ALOS

5 The ALC days and ALOS refers to the length of the ALC stay only and does not include the acute care time of the stay in hospital.



Also of note in Table 1 is that the average length of stay for all patients (5.7 days) versus the average length of ALC stage of stay (17.7 days) is more than a three-fold difference. For a rather substantial subset of

patients, it appears that the health care system has difficulty finding appropriate care in a timely manner, contrary to the vision of the ALC Task Group “Right Care, Right Place, Right Time”.

An additional analysis of the Provincial Health Planning Database data revealed that the number of ALC days in Central East LHIN hospitals has continually increased since 2004/05 when there were 37,235 reported ALC days. That figure rose to 40,845 in 2005/06 and to 60,692 in 2006/07 (a 63.5% increase over a two-year period)

which is the equivalent of 167 acute care beds being occupied by people who no longer require acute care in hospital and whose health care needs could be better met elsewhere. Sources such as the Ontario Hospital Association (OHA) ALC Snapshot Survey in February, 2008 and anecdotal information from Task Group

members indicates that this upward trend is continuing unabated. Table 1: Summary of Alternate Level of Care Data for Central East LHIN Hospital Sites The 2006/07 data were further broken down by each hospital corporation to determine the number of ALC

patients and days of stay according to the discharge destination. Detailed discharge destination information for the Central East LHIN as a whole is summarized in the pie chart in Figure 2: Percent of ALC Patient Days Categorized by Discharge Destination for Central East LHIN Hospitals 2006/07 on the next page.

(This information is also presented in a Table in Appendix 3.)

Hospital Name

Total

Cases

Total

Days

Total

ALOS

ALC

Cases

ALC

Days

Avge.

ALC

LOS

% ALC

Days of

Total

Days in

Site

Portion

of Total

ALC

Days

Lakeridge Health Corporation-Oshawa Site 16,567 91,079 5.5 892 11,007 12.3 12.1% 18.1%

Peterborough Regional Health Centre 14,385 94,013 6.5 321 9,586 29.9 10.2% 15.8%

The Scarborough Hospital- General Site 18,652 102,536 5.5 324 6,332 19.5 6.2% 10.4%

Ross Memorial Hospital 4,714 35,376 7.5 288 6,285 21.8 17.8% 10.4%

Northumberland Hills Hospital 3,823 23,174 6.1 314 5,313 16.9 22.9% 8.8%

Campbellford Memorial Hospital 1,106 12,017 10.9 73 4,890 67.0 40.7% 8.1%

Rouge Valley Health System-Ajax Site 8,066 37,687 4.7 299 4,564 15.3 12.1% 7.5%

The Scarborough Hospital-Grace Site 12,951 67,085 5.2 202 4,406 21.8 6.6% 7.3%

Rouge Valley Health System-Centenary Site 14,311 70,586 4.9 280 3,483 12.4 4.9% 5.7%

Lakeridge Health Corporation- Bowmanville Site 2,481 16,722 6.7 285 2,808 9.9 16.8% 4.6%

Lakeridge Health Corporation-Port Perry Site 1,716 8,134 4.7 130 1,652 12.7 20.3% 2.7%

Haliburton Highlands Health Services Corporation 486 4,188 8.6 11 366 33.3 8.7% 0.6%

Markham Stouffville Hospital- Uxbridge Site 815 4,950 6.1 11 181 16.5 3.7% 0.3%

Total - ALL Cases 100,073 567,547 5.7 3430 60873 17.7 10.7% 100.0%



Each hospital in the Central East LHIN has initiated a range of innovative strategies to try to address the ALC pressures and patient flow issues in their local area. These efforts have met with varying degrees of

success depending on the patient population, the internal hospital focus and resource allocation, and the local community availability of services and supports. The ALC Task Group recognizes that a more in-depth analysis is required in each Central East LHIN planning zone6 due to the complexity of the ALC issues

and the acknowledgment that finding solutions will require versatile approaches. Figure 2: Percent of ALC Patient Days Categorized by Discharge Destination for Central East LHIN Hospitals, 2006/07

For the nine hospitals in the Central East LHIN, in 2006/07 the highest numbers of ALC patients were discharged to a chronic care facility (845 people). Chronic care facilities are any facilities with chronic care

designated beds (including hospitals) or hospitals with complex continuing care beds; therefore, many of these transfers may have occurred within the same hospital. Prior to discharge to a chronic care facility, these patients accumulated 13,977 hospital days during their ALC designation which represented 23% of all

ALC days across the Central East LHIN that year. It is important to note that in some hospitals, a significant number of the people discharged to a chronic care facility are in fact still waiting for a long-term care home placement as their final discharge destination.

Although slightly fewer in numbers (834 people), 40.8% of ALC days were accumulated by patients that were discharged directly to a long-term care home.

Also of note is the fact that 10.6% of ALC patients died while awaiting discharge and accounted for 11.7% of all ALC days in 2006/07, the third highest percentage.

6 A brief profile of the demographics and health care resources in each planning zone is further described in Appendix 4.



Furthermore, the average length of stay for ALC patients who were eventually discharged home with supports (a preferred discharge destination for those capable of returning home with in-home supports) was

10.8 days. Further analysis is required to determine why individuals waited almost 11 days to go home; some of the reasons may indicate patients that were originally identified for other destinations improved enough to return home with home care support, it may indicate medical equipment or home renovations had to be

made prior to returning home, it may indicate limitations in the local home care capacity due to waitlists or human resource shortages, or it may suggest that there is room to improve the efficiency of the discharge planning process.

The above data must be interpreted with caution. As noted elsewhere in this report, the hospital data reflects where the person was discharged to, not necessarily what level of care they were waiting for or what

was needed. The discharge destination is not necessarily the location where people will receive the most appropriate care to meet their needs but rather, in a certain percentage of cases, may have been the earliest available, better known or ‘good enough’ destination. ALC Snapshot Survey As the ALC designation according to the CIHI definition only applies to acute care beds, those patients waiting in chronic care, rehabilitation, mental health or other beds for an alternate level of care are not

captured in the available data. Recognizing this, the ALC Task Group expanded the data capture beyond acute care in an attempt to get a more accurate picture of the local ALC issues. This was also true to their established vision – ‘Right Care Right Place Right Time’ with respect to all patients waiting for appropriate

health care, regardless of where they live in the Central East LHIN. To get closer to understanding what care and location destinations would be most appropriate for their

patients, in the summer of 2007 the ALC Task Group conducted a Snapshot Survey in the local hospitals. The purpose of the hospital Snapshot Survey was to determine the status of their ALC patients by asking the question, “What are ALC patients waiting for?” in recognition that the hospital discharge data identifies

where the patient was discharged to and may not indicate the optimum/appropriate type of care destination for the patient (e.g. decision was based on availability, preference, ability to pay, location, etc.). The overall goal of the survey was to better understand where investments could be most strategically directed to

support patients leaving the hospital setting. Six of the hospitals in Central East LHIN completed the survey and a summary of “What were ALC patients

waiting for?” is summarized in Table 2 below. Again, results must be interpreted with caution given the limited number of respondents and that the numbers reflect a point in time (snapshot).

The results show that a long-term care home was the destination most ALC patients were waiting for. The 58% figure is consistent with information provided by the literature and other data sources.



“We need to unfrail them.”

ALC Task Group member

Table 2: ALC Task Group Snapshot Survey: “What Central East LHIN ALC Patients Are Waiting For”, Summer 2007

Service Waiting for Percent

Long-Term Care Home 58%

Rehabilitation 13%

Convalescent Care 10%

Palliative Care 7%

Complex Continuing Care 6%

Home Care 2%

Mental Health 2%

Assisted Living/ Supportive Housing 1%

It was noted that very few patients were waiting for assisted living or supportive housing (1%) despite belief, based on field experience, that supportive housing could provide optimal support for a number of ALC patients. Upon further follow-up, it was determined that patients were not listed as “waiting for” assisted

living/supportive housing when: the service was not available locally, the patient could not afford the service (e.g. retirement homes),

there was no common understanding or definition of what assisted living or supportive housing could provide if it was available.

The ALC Task Group recognized that the most fundamental question to be answered was, “What care does the ALC patient need?” In an attempt to find the answer, the group mounted a follow-up pilot study.

Hospital Pilot Study To address the question, “What support does the patient need to leave the hospital?”, a small working group was formed to pilot-test an assessment tool in several Central East LHIN hospitals. The concept was to

conduct a simple qualitative survey rather than a rigorous assessment. The assessment tool was used to determine each ALC patients’ individual care needs and specific support

requirements to meet them. The working group attempted to establish needs based on commonly used categories including activities of daily living (ADL) such as eating, bathing, toileting; and instrumental activities of daily living (IADL) such as shopping and meal preparation. The survey also tried to match needs

with a range of potential service options. Given the time frame, resources and expertise of the working group members, the attempt to collect this qualitative data from all hospitals was finally abandoned. However, for the duration of the pilot study the following observations were made:

• A long-term care home is the only option currently available when a

person needs close or constant supervision due to wandering or highly

disruptive/challenging behavior. A Specialized Care Unit in a long-term care home is an appropriate alternate level of care for this group. Given the preponderance of dementia diagnoses among those waiting for long-term

care, it begs the question of what options could be created for this level of care.



• A long-term care home may become the discharge destination due to housing needs rather than care needs. This happens when the patient’s home living situation is considered unsuitable or

unsafe. (There are numerous reasons that living accommodations may be unsuitable including: stairs, inaccessible bathrooms, wood stove heating, isolation, financial hardship, or an abusive or non-existent support network.) Again, this begs the question of what alternative housing

options could be created for some seniors. • Some ALC patients had personal support needs such as assistance in dressing, meal preparation

or medication management (examples of IADLs). They may have lacked financial resources

or informal caregiver supports. Potentially, this represents a group of ALC patients with light to medium care needs that could be supported in assisted living/supportive housing accommodations if it was locally available and affordable for the individual/family.

• Finally, the essential question of what it would take to care for the ALC patients in the community in response to “what do they need?” could not be answered without a more rigorous approach through a properly designed study with tested assessment instruments.

Ontario Hospital Association (OHA) ALC Snapshot Survey The most recent Ontario Hospital Association (OHA) ALC Snapshot Survey7 provides further information

about the ALC issue in Central East LHIN. In February 2008, hospitals indicated that 250 of the acute care beds (equivalent to 18%) of the reporting hospitals in Central East LHIN were occupied by patients waiting for an alternate level of care and 62% of them (154 patients) were waiting for a long term care home

placement. This is further evidence that the percent of patients being classified as ALC is growing. The OHA ALC Snapshot Survey now asks hospitals to identify the number of patients waiting in an “Other”

in-patient bed (not ALC designated) for an alternate level of care. Central East LHIN hospitals identified 11% of “other staffed and operating in-patient care beds” as occupied by ALC patients and again, the majority was waiting for a long term care home placement.

In addition, the survey asked hospitals to self-report on the number of patients in the emergency department waiting for an in-patient bed at any given point in time. In Central East, hospitals identified 56 patients who

were spending hours and sometimes days waiting on stretchers in the emergency department. The length of waiting time in emergency and inability to access an acute care in-patient bed is considered to be directly and partly related to the ALC pressures.

7 OHA ALC Survey Results, February 2008.



Case Mix Grouping for ALC Designated Patients In addition to quantifying the size of the ALC issue and identifying discharge destinations of ALC patients,

the ALC Task Group thought ideas and solutions for providing appropriate care to these patients would be informed by an understanding of the most common case mix groupings.

Table 3: Top Case Mix Groupings for all ALC Cases details the ALC information for the top 15 case mix groups (CMGs). The patients that are spending the longest number of days with an ALC designation are from the following Case Mix Groupings (CMG):

1. Dementia with or without delirium with Axis III diagnosis 2. Specific Cerebrovascular Disorders except Transient Ischemic Attacks 3. Other factors causing hospitalization

4. Heart failure 5. Dementia with or without delirium without Axis III diagnosis

Considered together, the dementia related CMGs are even more significant. Patients experiencing cognitive impairment and/or behavioural issues including aggression, agitation or wandering require specialized services and supports to appropriately meet their level of care needs. There are limited resources in the

long-term care system to manage seniors with behavioural care needs or serious mental health issues in Central East which may cause extended stay in hospital and reduce opportunities for appropriate placement (hence increasing ALC days). The average age for the top 15 CMG’s for ALC cases is 79.8 years old.



Tabl

e 3: T

op 15

CMGs

for A

LC Ca

ses



Long-Term Care and the Role of the Community Care Access Centre Along with coordinating the provision of home health care and support services, the Central East

Community Care Access Centre (CCAC) is provincially mandated to manage admission into long-term care homes (LTCHs)8. The Central East CCAC is responsible to take applications and determine eligibility and priorities for admission as well as manage the waiting list for short-stay and long-stay placements in

accordance with applicable legislation. The occupancy rate in LTCHs in Ontario has increased from 95.6% in 2006 to 98.0% in 2008 and the average

age of admission is 87 years old. Throughout the Central East LHIN there are 9,572 total LTCH beds including short-stay (63), interim (34)

and convalescent care (75). In the end of month MOHLTC Health Data Branch report for February 2008, the LTCH long stay utilization rate was 98.9%. There are over 400 new clients waitlisted per month and the year to date waitlist (April 1 2007 – February 29, 2008) was 3,026 people (up to 4,468 including internal

transfer requests from third or second choice to first choice LTCH). People wait on average 53 days (3rd choice home) to 116 days (1st choice home) to get placed. The average length of stay in a LTCH in Central East is 2.8 years.

Patient finances can also impact the ALC length of stay. Long-Term Care Homes are required to provide a minimum 40% basic accommodation beds and a maximum 60% preferred accommodation (semi-private and

private) beds. ALC patients who cannot afford the additional costs for preferred accommodation often have a longer length of stay in hospital as the basic accommodation beds are typically full. Similarly, a patient whose appropriate level of care needs could be met in a private retirement residence may not be able to

afford the cost of care and therefore remains in hospital while waiting for a LTCH, even though a LTCH may provide a higher level of care than is required.

ALC patients who have complex medical needs or severe behavioural issues are considered “hard to place” in LTCHs and these individuals have considerable impact on ALC pressures. LTCHs are challenged to provide the higher staffing levels and appropriate staffing qualifications to care for this most vulnerable

population and they may refuse a person’s application because they do not have the nursing expertise or environment to provide appropriate care.

The ability for CCAC to place individuals in long-term care homes is severely compromised when access is so limited due to occupancy rates, affordability, and complex care or behavioural needs.

8 CCACs do not manage admissions to chronic care hospitals or rest/retirement homes or group homes.



GTA Rehab Network Survey In a snapshot survey conducted February 5, 2008 in two Toronto area community

hospitals and its member rehabilitation hospitals, the GTA Network found that 4% of the total number of occupied rehab beds was patients waiting for an alternate level of care.9 Of these, 59% were waiting for long-term care home

placement. The survey also found that 14.5% of the Low Tolerance Long Duration (LTLD) rehab in complex continuing care beds was patients waiting for an alternate level of care, and 87% were waiting for long-term care home placement.

Patients had been waiting between 8 and 250 days for a LTCH. Although the GTA Network Rehab survey was conducted in Toronto, ALC in

rehab beds is an emerging issue that impacts residents in the Central East LHIN. It is estimated that the number of ALC patients is under-reported due to inconsistencies in ALC tracking processes and the absence of a definition of ALC

for rehab that can be used across programs. Hospital patient flow process map The members of the ALC Task Group undertook an extensive process of developing a patient flow process map (see Figure 3: Patient Flow Process Map) that follows a patient’s journey from acute care hospital admission to designation as an ALC patient to the optimal level of care discharge destination

based on the patient’s level of care needs. Once the patient flow process map was completed, meetings were held with selected staff at each of the nine hospitals in the Central East LHIN to review the process map and list any barriers/issues they perceived at each decision-making point in the patient flow process.

If barriers/issues were identified, the selected hospital staff was asked to document the reasons why the barrier was occurring.

The ALC Task Group compiled this individual hospital information into a single working document that gave a complete list of all the barriers/issues for each step of the patient flow map specific to the Central East LHIN. ALC Task Group members searched the literature to identify any evidence-based practice(s)

or innovations that could be applied locally to address the identified issues. Through their deliberations of possible solutions, the ALC Task Group developed their recommendations for this report.

9 GTA Rehab Network, Beyond Acute Care: Next Steps in Understanding ALC Days. March, 2008

“Given the wait times for LTC reported in the GTA Rehab Network survey, it is clear that patienst waiting for LTC beds in either rehab or CCC beds are beginning to create bottlenecks at the end of the inpatient continuum, affecting the movement of patients into rehab and through the healthcare system.”

Beyond Acute Care: Next Steps in Understanding ALC Days

GTA Network, March 2008



Fi

gure

3: P

atie

nt Fl

ow P

roce

ss M

ap



ALC Discharge to Appropriate Discharge Referral Destination In Figure 3 (on previous page), when the ALC designated patient moves to the “Confirm Alternate Discharge”

decision point, an assessment to determine the optimal care discharge destination for the patient for an ALC patient is based on four considerations typically used in practice: ACCESSIBILITY, ACCEPTABILITY, AVAILABILITY, and FEASIBILITY. These informal criteria are described below:

Accessibility: Access may be described in several ways. The first question is to determine if the optimal

care discharge destination is available close to person’s home and if so, whether or not the

persons’ needs meet the eligibility criteria for the service/program. If the persons’ needs can be met and he/she is eligible, the question becomes, “Is there an available vacancy?” If the optimal care destination is a geographic distance away, are there transportation barriers to

access for either the patient or for visiting family members? Acceptability: The services provided must meet the expectations of the service users and their families.

Patients have a choice about where they will receive care. The patient and/or substitute decision-maker may refuse the assessed optimal care discharge destination.

Availability: There are communities throughout the Central East LHIN region that do not offer a full basket of services either because the service does not exist or long waiting lists preclude the service as an option and it is unavailable as a discharge destination; for example, supportive

housing or assisted living options. In these situations, referrals are not even considered or offered although it may be assessed as the most appropriate level of care for the patient.

Feasibility: The patient and/or family may not be able to afford the cost of care for the optimal care discharge destination; for example, retirement home care or in-home supports and the alternate level of care is not feasible.

Any wait times for either an optimal or alternate discharge destination will result in an ALC

designation for the patient.



For patients over 74 years old, “…by the second day of admission statistically significant deterioration had occurred in individual scores for mobility, transfer, toileting, feeding and grooming.”

Carla Graf, AJN Jan 2006, Vol 106, No. 1 p. 60.

Overview of the ALC Challenges in Central East LHIN ALC is a long-standing, complex, system-wide issue with serious

implications for health care across the province. It represents challenges related to patient flow, integration, access, capacity and resources. The inappropriate placement of non-acute patients in acute care beds

has a domino effect throughout the system. With decreased access to acute care, elective surgeries have to be cancelled and acutely ill patients have long waits in the emergency department for an

in-patient bed.

Challenges 1. Patient-centred care Typically described as a health services issue, the hospital data and systems discussions fail to capture the emotional and physical stress and quality of life issues that the patient and his/her family experience while waiting

for an alternate level of care in an acute care bed. For many older adults, hospitalization can be a catastrophic event for them and their families. Effects of an illness can ultimately threaten the person’s ability to live

independently and they end up making difficult life decisions about where to live when they leave the hospital.

Not only can it be very difficult to be asked to make unexpected or unplanned decisions about moving to a long term care home, there are serious health risks associated with remaining in hospital while waiting for an alternate level of care. Risks include hospital-acquired infection, loss of physical, mental and social

function, and built dependency on the health care team. Studies show that 34% - 50% of seniors experience a decline in their functional status between hospital admission and discharge.10 The loss of functionality may be as much as 5% every day due to inactivity and lack of stimulation and can be permanently debilitating –

increasing the risk for institutionalization - simply as a result of waiting for appropriate care. If the health care providers and the family “expect” the frail elderly patient

to become increasingly weaker and disabled, it can become a self-fulfilling prophecy by the patient. Over a few days, the only hospital discharge plan that is even considered is a long- term care home placement. On the other

hand, a proactive patient-centred approach that educates families about what an ALC designation means and that supports earlier preparation and discussions about hospital discharge options (including short-term options

while waiting for a LTCH) may change expectations about independence and future care needs.

10 Doherty King, B.,MedSurg Nursing Journal of Adult Health, October 2006 Vol 15, No. 5, p. 265.

“Access and wait times: whole patient care requires a whole care system…This implies a need for a comprehensive review of the whole care system, rather than a narrow focus on either primary or secondary are, or on wait times.”

Canadian Medical Association: Taking the pulse of specialty care: an online

consultation with Canada’s physicians, July 2007

“…comprehensive resolution of the ALC problem requires a system orientation and collaborative approach by LTC homes, CCACs and other community providers as well as hospitals.”

Ontario Hospital Association Ontario Assoc. of Non-Profit Homes and

Service for Seniors



The ALC Task Group assumes that receiving care in one’s home is the first choice option, whenever appropriate.

The ALC Task Group identified that there is also emotional stress for the ALC Discharge Planners/Social Workers. They are pressured by the hospital to move ALC patients to an appropriate level of care as soon as

possible but they experience difficulties managing patient and family expectations regarding post-hospital discharge destinations and/or they lack timely access to appropriate discharge destinations. As a result, patients are discharged to the first available alternate level of care (and may continue to be ALC in a

different part of the hospital) versus the most appropriate level of care and the Discharge Planner is perceived to be “heartless and unsympathetic” to the patient and family situation.

2. Definition of ALC and ALC Data Collection CIHI collects information on the number of ALC patients in hospital, the type of patient (diagnosis), the level of care required, and the number of post-acute days spent in the acute care bed. This ALC indicator is used

to measure the extent to which hospitals are able to maximize their resources and their ability to move patients on to appropriate levels of care in a timely manner. The mandate of the ALC Task Group was limited to the hospital ALC patient waiting in an acute care bed as defined by CIHI.

The hospital data describes large and increasing numbers of ALC patients. However, it does not capture the true numbers of ALC patients (or “hidden” patients) and is a likely under-estimation of actual numbers for

two reasons: i. The ALC definition is inconsistently applied across hospitals. The process for determining when a

patient becomes post-acute and is designated ALC is not standardized and current data is not reliable.

ii. An ALC designation only applies to acute care patients and not to other levels of care within the hospital. At this time, hospital data is not systematically collected for patients/clients waiting for discharge to a more appropriate level of care from other parts of the hospital (e.g. in rehabilitation,

mental health, interim beds, complex continuing care beds).

The number of days that a post-acute patient waits in hospital for an alternate level of care is an indicator of

the degree of hospital and community integration and the resources available in the non-acute care settings. Anecdotally, the common impression is that more than 10% of ALC patients are inappropriately placed in a long term care home as the “default” setting or only option out of hospital due to a lack of

accessible/available or affordable community resources. The collection, analysis and management of high quality clinical and administrative data are essential to

ensuring continuous improvement in the efficiencies and effectiveness of the system to move patients across home, community and hospital care.



“The safeguards in place to conserve autonomy in choosing one’s place of residence are frequently identified as a barrier to effective utilization of acute resources.”

Ethical Issues of Access for Patients Requiring Long Term Care Home

Placement Final Report, April, 2008, p. 3.

3. Risk identification There is no mandatory screening in the hospital emergency or inpatient unit

to identify patients who are at high risk of becoming an ALC patient. With early detection, assessment and discharge planning, people could begin to receive community-based services and be diverted from emergency and/or

prevent hospital admission/re-admission. Enhancing the range and level of services for seniors living at home (such as supportive housing, income supports, enhancing social networks, increased in-home supports for daily

living) may avoid hospital admissions and delay premature placement in long-term care homes. 4. Capacity of Community Services to enhance patient flow Effective patient flow can only be optimized at the system level. The movement of patients in and out of hospital is strongly influenced by the availability and affordability of local services. There is insufficient and varied access to home care, supportive housing/assisted living, long-term care homes, palliative care,

rehabilitation or complex continuing care across the Central East LHIN. Long waiting lists can preclude hospitals from referring to the optimal level of care for the patient and encourage discharges to less appropriate levels of care destinations. The ALC Task Group estimates that 20 - 30% of the ALC patients

are moving to a sub-optimal alternate level of care while they continue to wait for an appropriate location for health care to be delivered.

The Central East CCAC is provincially funded to coordinate the provision of home health care and support services for a specific number of hours/visits per month based on an individual’s assessed needs under service maximums set out in provincial regulations. Unfortunately, the current limitations on the maximum

hours that a person can receive is often not enough to keep the person out of hospital or to be maintained in their own home.

Long waiting lists for community services may also promote premature placement of post-acute people in long term care homes. Hospital staff will refer the ALC patient to a long-term care home because they know that even if a more appropriate local supportive housing service exists, there is more than a three year

waiting list for placement. Without adequate capacity of community resources people cannot return home and there will continue to be

increasing numbers of patients “bottle-necking” the system waiting in hospital for appropriate levels of care. Hospital staff has indicated that they lack information about what

community programs are available, how to refer or what level of care they offer. This fragmentation can lead to inappropriate referrals and/or inappropriate levels of care.

Patient income can also be a factor in determining the most appropriate discharge destination. For example, an unregulated retirement home or own

home with fee-for-service supports may be able to meet the patient’s care needs; however, if the patient cannot afford the care he/she must wait in hospital for a LTCH placement.

“Many people designated ALC have very precarious health issues and cannot go home safely without a lot of care.”

Dr. Peggy Wilkins Family Physician



Similarly, ethnicity and language are important considerations in determining the most appropriate discharge destination. For example, a Long-Term Care Home may be suitable to meet the patient’s care needs but the

patient’s first choice is a facility that can meet their unique cultural and linguistic needs. 5. Long-term care home placement The legislations and policy regulations under the Ontario Hospitals Act and the Ontario Long-Term Care

Home Act have conflicting rules and regulations which causes tension and frustration within the system. Hospitals are pressured to reduce their ALC days and to discharge non-acute patients as quickly as possible.

On the one hand, the hospital staff will not send someone home who is at-risk or unsafe even if she is no longer an acute care patient. On the other hand, CCAC acts as the gatekeeper to access LTCH placement and the CCAC cannot proceed with a long-term care home application without the patient’s consent.

Designated ALC patients who are unable to return home are given a choice about the LTCH where they want to live when they leave the hospital. However, this can cause an ethical dilemma for both the hospital health

care professionals and the CCAC health care professionals. Every patient has a right to select which long term care home(s) they prefer. If the patient is offered an available vacancy in a LTCH that is not one of their choices, they may refuse the offer and remain in the ALC bed. This causes delays in the ALC discharge

planning process and extended lengths of stay in hospital. It can also cause frustration for the health professionals involved as they feel “hospitals are held hostage”. Some hospitals advocate that a patient should not wait indefinitely in a hospital bed in order to satisfy a preference. Unfortunately, the patient

gets caught in the middle. 6. Specialized Services One of the biggest ALC pressures in the Central East LHIN is the high number of people with dementia with Axis III Diagnosis that are unable to access a LTCH due to the behavioural needs (such as aggressive or difficult to control behaviours) caused by their illness. This population of ALC patients is considered

“hard-to-place” because they require specialized resources and therefore, have the longest average length of stay in hospital. Long-term care homes are reluctant to admit the hard-to-serve ALC cases because they do not have the trained staff or specialized care units to manage this vulnerable population that can put

themselves, other residents and staff at risk of harm. Similarly, ALC patients with specialized medical needs (such as peritoneal dialysis) are being cared for

in hospital when they could receive care in a LTCH. However, there is a lack of geriatric expertise or specifically trained staff available to work in the LTCHs.

7. Health Human Resources Health human resources are a critical enabler across all components of the patient flow process. Appropriate management and training of health providers is key to ensuring that the patient has access to the service that

they need at the place and time that they need them.



Workplace Safety and Job Satisfaction

There are several reports and documents that examine the challenges of trying to address ALC issues and the

impact on the health care system. There is much less focus on the effect caring for ALC patients has on the healthcare staff. In an interesting study conducted by the Canadian Health Services Research Foundation in British Columbia11, it was found that staff members are at more risk of injury (particularly licensed practical

nurses and care aides) because of the unpredictable behaviour of the ALC patients. They also found staff that was not told that they would be working with ALC patients when they were hired were at higher risk of burn-out, job dissatisfaction and poor health. Registered nurses regard care for stable, elderly patients as

“low status” and unchallenging work compared to their training. This may negatively impact morale and staff retention. Ethnocultural and Diversity Considerations

The Central East LHIN is an area with a diverse population of residents with different linguistic and ethnocultural needs. Peoples’ cultural values towards family, the elderly, illness and health care; particularly

towards hospitals, long term care homes and in-home supports, impacts attitude and acceptance of various treatment interventions and care settings.

The varied language and cultural expertise of the health service providers also impacts the ability to identify patients that are high-risk to become ALC (and to intervene early to put community supports in place) and to support discharge planning and appropriate levels of care options.

Recruitment, Training, Retention

With new funding initiatives and the allocation of new resources, health providers must find and retain

qualified people to actually deliver the services. This will require focused recruitment and retention planning efforts and a Central East LHIN-wide strategy so that community agencies are not competing for the same limited resources.

Mentoring programs and education opportunities that are linked to the human resource health professional demand should be promoted. The lack of skilled health professionals may limit the ability to implement the

ALC Task Group recommendations as services will not have the capacity to expand.

11 Yassi, A. et al (2002). Caring for the Caregivers of “Alternate Level Care” Patients: The Impact of Healthcare Organizational Factors

on Nurse Health, Well-being, Recruitment and Retention in the South Fraser Region of British Columbia, CHSRF.



Opportunities and New Initiatives The challenges presented by Alternate Level of Care develop over time and often reflect a lack of early

intervention or community supports that can postpone the loss of a person’s functionality and delay or avoid hospital admission. By viewing the system as a whole one can see that there are targeted opportunities to reverse the patient trajectory from independence and quality of life to dependence and poor health (see

Figure 4: ALC Trajectory12). The literature shows that an important strategy with a high impact on reducing ALC pressures is to intervene at the earliest possible stage of care to maintain people in the community. Figure 4: ALC Trajectory

12 The framework was developed by the Ottawa Regional Geriatric Assessment Program and illustrates the LTCH placement trajectory

for the elderly population.



As reported in the collaborative position paper, Alternate Level of Care- Challenges and Opportunities: Although ALC patients are only one component of an extremely complex system, they have a significant

impact on optimal patient flow and use of resources. This impact reverberates right through the system from EMS to hospitals to home care and LTC homes. It also compromises the quality of the public’s experience of the health system (p.17).

There are several initiatives currently being pilot-tested or proposed through Ministry of Health and Long Term Care provincial funding initiatives such as: Aging at Home Strategy, Wait Times Strategy, Emergency

Wait Times Strategy, Primary Care Renewal, HealthForce Ontario, Chronic Disease Management and Prevention Strategy, and eHealth. The ALC Task Group consulted with other regional working groups in the Central East LHIN and in other parts of the province to look at coordination and integration opportunities

that may help alleviate the ALC pressures. Ongoing dialogue and synergy across the initiatives and Task Groups facilitates innovative system solutions and must be supported if access and patient flow is to be improved. Brief descriptions of some initiatives (this is not a complete list) that are expected to impact

ALC are listed below. The Flo Collaborative The Flo Collaborative is an Ontario Health Performance Initiative intended to reduce the Alternate Level of Care days in the province. The Flo Collaborative is designed to improve the timeliness and effectiveness of transitions for care and focuses on process improvements through quality improvement teams. Peterborough

Regional Health Centre is a pilot site for this strategy. It is focusing on patient flow issues within the hospital, the use of visual communication tools for patients, their families and staff and is expected to transfer their knowledge to all Central East LHIN hospitals at the end of the 18 month pilot. Home at Last This program helps transition people ready for hospital discharge home without relying on family/caregivers to provide transportation, pick-up prescriptions and other essentials, and facilitates links with community

support services. It is expected to reduce return emergency department visits and reduce departure delays. Geriatric Emergency Management (GEM) Nursing There are five pilot sites across the Central East LHIN that have GEM nurses to provide clinical services to at-risk seniors in the Emergency Department. They use a standardized and consistent model for the management of frail seniors at each site. In the first three months in four of the sites, 8085 eligible patients

were identified, 672 were seen be the GEM nurse in the emergency department and 41% were admitted. It is expected that there will be fewer admissions of patients who subsequently become ALC through this early identification and intervention.

Timely Discharge Information System Demonstration Project This project supports the timely delivery of patient admission/discharge information to their primary care

practitioner by reviewing and redesigning the workflow process and systems to facilitate the exchange of information.



Toronto Balance of Care Research Project The Toronto Central CCAC recently completed a research project (November 2007 to February 2008)

in partnership with the University of Toronto and Ryerson University. The Balance of Care (BoC) project documented the key characteristics of over 1600 individuals waiting for long-term care beds with the aim of determining how many could be safely and cost-effectively supported at home if given access to integrated

home and community care packages. Packages could include professional services (e.g. nurses, social workers, and rehabilitation therapists) as well as community supports (e.g. meals-on-wheels, transportation, homemaking, day program, respite). This project was supported with funding from the Canadian Institute

of Health Research (CIHR). The BoC model (1990) is a methodology developed by Dr. David Challis at University of Manchester in the

UK to determine the most appropriate care setting and mix of resources required to sustain frail seniors in the community. The key question it answers is “What proportion of frail seniors deemed eligible for LTCH placement could be maintained at home if given access to appropriate community-based care packages?”

The study used the standard Resident Assessment Instrument-Home Care (RAI-HC) assessment tool. The key findings were that IADLs emerged as a key driver of long-term care home waitlists. Almost 65%

of waitlisted individuals experienced a high degree of difficulty with daily tasks such as bathing, locomotion and hygiene. It was estimated that roughly 50% of Toronto LTC waitlisted individuals could be maintained in the community if more integrated care options such as supportive housing and cluster care were

available. On the other hand, 20% of those on the waitlist had high levels of care needs that would not be cost-effective or appropriate for community services.13

This study did not address whether the ALC patients waiting for long-term care while in hospital had characteristically different (higher) levels of care needs. They are currently looking to expand the study to other parts of Ontario.

Increased Scope of Practice for Registered and Non-Registered Staff This program offers enhanced skills training for registered and non-registered staff that is providing direct

care in LTCHs so that they may better assess health care needs and intervene earlier in a health crisis. (This successful Central East program won recognition at Celebration Innovations in Health Care Expo 2007 and again in 2008).

Central East LHIN Aging at Home Strategy Through the three year provincial Aging at Home Strategy, the Central East LHIN has prioritized “care

for the caregiver” supports, community support services and supportive housing initiatives in Year One. Increased funding in the community to provide necessary personal supports to enable people to maintain their independence and “age at home” is expected to reduce the need for either acute care or the level

of care provided in a LTCH. This will positively impact the ALC pressures in hospital.

13 Toronto Central CCAC Communiqué, Spring 2008.



Recommendations The recommendations in this report are aimed at creating a comprehensive system of care to meet ongoing

needs. In combination with several initiatives already underway or being piloted in the Central East LHIN, it is anticipated that individuals will find it easier to move from one type of care to another and that there will be a subsequent overall 30% reduction in ALC days over the next three years.

Based on the analytical discussions, qualitative and quantitative data collection, review of provincial and other reports, and feedback from the community consultation processes; the ALC Task Group has created

52 recommendations that have the potential to ensure the right level of care is delivered in the right place and at the right time with the right resources.

The Central East LHIN ALC Task Group has developed recommendations for strategies that focus on both resource and capacity issues and on improvement in processes of care delivery. Some of the recommendations reflect the best practices and activities that are already in place or have been already

tried by some of the hospitals in the Central East LHIN. It is not expected that all of the recommendations will apply to all settings but it is hoped that due consideration will be given to each one relative to the specific ALC pressures experienced at the local level.

The recommendations are organized into six overall themes:

1. Presentation at Hospital: Risk Identification and Early Intervention

2. Patient Flow and Communication in Hospital: Acute and Post-Acute Care 3. System Access and Smooth Transitions across Continuum of Care 4. Community Capacity and In-Home Care

5. Health Human Resources 6. ALC System Monitoring and Evaluation

All of the recommendations are considered to be essential in addressing the continually growing ALC problem in the Central East LHIN but they will take time to implement; therefore, the ALC Task Group identified 12 locally targeted recommendations and one provincially targeted recommendation that are

anticipated to have the highest impact on ALC within the next one to two years when implemented. The priority recommendations are bolded below and further described in a proposed Implementation Action Plan.

1. Presentation at Hospital

Risk Identification and Early Intervention Context:

• Individuals arrive at hospital Emergency Department with very little information about their living situation or psychosocial needs; e.g. without medications, alone, limited ability to speak English, difficulty coping

• Psychosocial issues not able to be addressed (families/caregivers “burnt out”, refuse to take family member home), limited social work availability in ER



• Few tools or programs in place to assess and divert seniors at high risk for becoming ALC patients in emergency department

• Hospitals do not have access to community pharmacies and laboratories to enable flow of patient information

• Shortage of Emergency Department (ED) health care professionals with training/skills to provide

geriatric assessment • Delays in response time, poor internal referral processes from emergency to hospital admission • Unclear roles re: CCAC, Discharge Planners, GEM Nurses, Social Workers

• Person’s discharge may be delayed due to lack of timely assessment • Social Workers, Discharge Planners not available weekends, after-hours • Unrealistic family and client expectations of hospital system and a lack of client involvement

in discharge planning early in the process • Hospital staff are often unfamiliar with community resources • Lack of access to community services (transportation, pharmacy, personal support, home help,

LTCH) at night or insufficient capacity or non-existent services in some areas

Presentation at Hospital Emergency Department 1. a. Utilize standardized risk screening and assessment tools for the early

identification of people in emergency department at high-risk for “failure to cope”

or a “medically unnecessary” admission;

b. When a person is identified at high-risk, facilitate the early intervention of

community supports and services to prevent hospitalization.

2. Provide specialized staff resources in each hospital Emergency Department

(days and evenings 7 days/week) to inform and support clients, families and

caregivers with regard to their options, including what community supports are

available and how to access them (i.e. Social Workers/Discharge Planners to

cover evenings and weekends).

3. Develop Emergency Department discharge protocols with linkages to community services including: psychogeriatric outreach teams, attendant care outreach, personal support services, supportive housing, local pharmacies and family physicians, and enable flow

of patient information.

4. Continue and expand the presence of Geriatric Emergency Management Nurses in Emergency

Departments across Central East LHIN.



In-Patient Acute Care Admission 5. Educate in-hospital providers about the role and capacity of community services available to

provide health care (in their catchment area) including medical management in the home.

6. Develop an enhanced comprehensive community services discharge planning process

for acute care patients screened at high risk that begins upon admission (or earlier)

in order to avoid/delay anticipated decline.

7. Increase access to Geriatricians and Psychogeriatric Specialists through utilization of Telehealth Network for days and evening access (7 days/week) to consultation from specialized resources such as CE Clinical Specialty Program.

8. a. Implement a standardized risk screening tool to identify seniors at high-risk to be

designated ALC (e.g. CCAC CIAT);

b. Repeat screening at regular intervals during an acute care hospitalization and use in combination with a standardized psycho-social screening tool to identify seniors that requiresocial work (e.g. The Scarborough Hospital Vulnerability Tool or the Camberwell

Assessment of Need Clinical – CAN-C); c. Augment the RAI needs assessment tool with a score for personal and family support resources to accurately determine the level of care needs and the potential of going home

with supports as a first option. Public At-Large

9. Develop a comprehensive public awareness/education strategy about what families can do to prevent hospitalization, when to go and what to bring to hospital, and what ALC designation and discharge options means.

Benefits:

• Standardized approach

• Clear roles and expectations • Improved coordination between hospital and community; early identification and comprehensive

service planning will decrease ED visits and hospital admissions

Risks:

• Cost of extending hospital staff hours

• Current lack of community resources to refer to



2. Patient Flow and Communication in Hospital Acute and Post-Acute Care

Context:

• Operational definition of ALC is not standardized and is not consistently used by all physicians or

across all hospitals • Findings identified inconsistencies in the timing of referrals relative to ALC designation • Assessment process is not consistent across hospitals or health service providers

• ALC Policy and its implementation is not consistent across hospitals • Fragmented approach to patient flow, lack of system integration • Lack of specialized resources/people trained in complex discharges

• Physicians may be unwilling to discharge (e.g. delay discharge while awaiting lab test or so patient can “gain strength”, won’t discharge another physician’s patient, not a clear understanding of implications of ALC designation)

• ALC discharge requires the order of a Medical Doctor • 18% of acute care beds in Central East LHIN are occupied by ALC patients • Optimal choices are not investigated due to the lack of access/availability; person referred to

sub-optimal (less appropriate to meet needs) alternate level of care setting • Referral forms are time-consuming; eligibility is not standardized

Recommendations:

10. Create and implement a Central East LHIN standard policy framework for the

management of ALC issues including:

• Designation of ALC (by care team and/or ACTIV criteria)

• Co-payment initiation (once LTC application is completed)

• LTC choice list guidelines (at least 1 short waitlist and 2 others)

• Principle of waiting in an out-of-hospital setting (e.g. LTCH) for LTCH bed

• “First available bed” procedures (100 – 150 km radius)

• Actions responding to refusal of bed offers (per diem fees)

• Standardize a consistent ALC Policy and its’ implementation across all

hospitals in Central East LHIN

• Develop a consistent triage/assessment process to delineate levels of care (e.g.

home with supports, supportive housing, LTCH, home without supports, etc.)

11. Expand definition and recognition of ALC beyond acute care bed spaces to include

all patients waiting in post-acute beds for an alternate level of care (such as complex

continuing care, rehabilitation beds).

12. Implement key lessons from the Patient Flo Collaborative to promote communication and coordinate quality care within hospital (among emergency, acute, complex continuing care/rehab/palliative and ALC).



13. Upon admission and/or designation as an ALC patient, begin to manage possible expectations/assumptions around “waiting indefinitely in hospital” through clear

communications with patients and families about discharge planning and benefits of a LTCH lifestyle.

14. a. Provide advance notification to CCAC and involve in discharge planning prior to decision to await LTCH placement; proactive counseling from CCAC Case Manager regarding community supports may be instrumental in achieving the waiting at home options;

b. CCAC to complete LTCH eligibility assessments while patient is in the hospital.

15. Provide in-hospital activation/exercise program to maintain optimal functionality

and mental wellness while in-hospital and continue program while waiting for

alternate level of care placement.

16. Implement benchmarks/timelines for ALC designation and discharge; extend discharge planning to weekends and after-hours.

17. Implement Home at Last across Central East LHIN to ensure a successful transition from 24 hours care to episodic care by making sure basics are in place such as food, medications, home safety, help contacts and transportation.

Benefits:

• Common approach to ALC designation

• Standard process for optimal discharge destination decisions • Reduced ALC ALOS days • Enhanced accessible/available community supports will delay or eliminate need for LTC

Risks: • Physicians do not adopt standardized practice

• Broader ALC definition demonstrates much bigger issue than already determined • Inconsistent implementation of standard ALC Policy • Lack of community readiness to expand capacity



3. System Access and Smooth Transitions Across Continuum of Care ALC Discharge and Referral Destination and Patient Flow

Context: • Policies, legislation and right of choice for LTCH placement may limit opportunity for

optimal discharge • Patients and/or families may be unable or unwilling to discuss discharge options • Patients have right to choice and may refuse discharge recommendation (choose to stay in

hospital while waiting for preferred option) • Lack of a consistent process for referrals to different discharge destinations (LTC, rehab,

ABI, CCC)

• Lack of coordination between hospitals and in-home care; CCAC has limited availability after hours

• Application processes are very time consuming and delay discharge; patients decline in function

and increase dependency while waiting for an appropriate setting • Waiting lists and resources vary from program to program; there is lack of a managed system to

remain informed of current availability in a timely way

• Optimal levels of care may not even be investigated because there is a perception that they are totally unavailable or un-accessible (due to long wait lists); referrals made to the quickest option

• Many elderly patients become more debilitated while in an ALC bed (lose up to 5% of

functionality/day) and must be reassessed for optimal level of care • CCAC hours of service maximums are not enough to maintain a person at home • Approximately 60% of ALC patients in Central East LHIN are waiting for LTC home

• Increasing number of hospitals given 1A crisis priority status (should be admitted to a LTC home within 7 days) who receive service before people waiting for LTC in an ALC bed

• Access to CCAC assessments for LTC placement is too long, further delays discharge

• Limited LTC home capacity; current LTCH utilization rate is 98.9% • Complicated application process to access short-stay LTCH beds • Limited rehabilitation/CCC beds capacity

• Inadequate community resources (i.e. supportive housing, in-home care, attendant care) • Lack of LTCHs capacity to support individuals with behavioural issues (e.g. dementia) or complex

medical needs; one of biggest ALC pressures in Central East LHIN

Recommendations: Improved Processes

18. Develop a one-call access system to enable referral to multiple LTCH locations with clearly described admission criteria and a common referral form.

19. Establish benchmarks and timelines from ALC designation and destination referral to

admission

to appropriate level of care (e.g. LTCH, complex continuing care, rehabilitation).



20. Implement a formal reassessment process with set timelines and benchmarks while person is designated ALC to ensure discharge plan remains current.

21. Implement recommendations from the Patient Flo Collaborative to streamline application

processes to community or LTCH services.

22. CCAC to create a centralized waitlist and vacancies list for LTCHs (including types of

care/specialties) that is updated daily along with a short-list with one month availability and

make available to all hospitals; implement an e-Referral process across Central East LHIN (see model currently used in Scarborough).

23. Implement a transparent process; when a referral is rejected or waitlisted the provider must give specific reasons for refusal.

24. Set priority placement threshold for patients waiting in hospital for LTCH greater than 60 days.

25. Change the CCAC spousal reunification waitlist priority to apply only to spouses/partners

where one person is already a resident in LTCH. Increased Community Capacity

26. Review the capacity of various funding models to increase the availability of housing

by using retirement homes and/or supportive housing respite beds to offer enhanced

care for ALC patients with light to medium level of care needs (e.g. review the

partnership model developed by Peterborough Health Services and the successfully

run program at The Scarborough Hospital).

27. Provide training and financial resources to encourage specialization to create

Behavioural Support Unit(s) within LTC homes that include short-stay transitional

beds for people with temporary cognitive decline and permanent beds for people

with ongoing behavioural management needs.

28. Increase the number of Psychogeriatric Resource Consultants to provide additional hours of

education/support to LTCHs (and increase the confidence of the LTCH staff to accept people with behavioural needs in the general population); expand service to educate community in-home health service providers.

29. Maximize utilization and appropriately fund short-stay respite beds (including timely and

efficient application processes).

30. Maximize use of convalescent care beds in LTCHs to support people from hospital to going

home (as a bridge between hospital and home).

31. Renovate Class C LTC homes to increase acceptability and preferred choice by ALC patients.



Benefits: • Reduced ALC beds and ALOS

• Range of placement options appropriate to level of care needs • Equitable access to LTCHs

Risks: • Individual may be transferred between placements which puts frail elderly person at higher

risk for hospitalization

• Financial costs to implement (training equipment, specialized resources) + capital costs • Increased pressures/demand for community services • Increase in acute care beds (with reduction in ALC beds) is more costly to hospitals

4. Community Capacity and In-Home Care Increase community capacity and support to individuals to remain in their own home as long as possible. Context:

• LTCHs reaching capacity (currently 99% occupancy in CE LHIN) • Long wait lists for community services; most agencies at capacity • Some areas of LHIN do not offer services (don’t exist) and agency service delivery boundaries may

limit access to another area • Eligibility criteria for CCAC services and application processes can pose barriers • Current regulated service limitations prevent CCACs providing required level of care required to

keep at home

Recommendations: 32. Extend CCAC service maximums set by provincial regulation for nursing, home-

making services and enhanced personal support and the capacity for occupational

therapy and physiotherapy to keep clients in the community as long as possible

and to delay LTCH placement.

33. Increase community support services for in-home personal support, homemaking and

caregiver respite.

34. Subsidize fees for community support services (e.g. adult day programs, transportation, meals

on wheels) for low-income seniors and people with physical disabilities.

35. Expand multi-disciplinary Psychogeriatric Outreach Teams to provide intensive level of

ongoing supports; expand to include LTCHs.

36. Increase supportive housing, rent geared-to-income and assisted living options including

Attendant Care Outreach throughout Central East LHIN.



37. Create and enhance community supports (e.g. in-home/out-of-home respite, adult day programs, transportation, Instrumental Activities of Daily Living - IADL) and alternatives to

long term care placement.

38. Ensure a core basket of community services (including but not limited to homemaking,

Meals on Wheels, transportation, personal support) is equitably available across the Central East LHIN.

39. Develop a strategy for the provision of physician care to “orphaned patients” to enable the provision of CCAC services.

Benefits:

• Coordinated care across hospital and community will potentially divert hospital emergency admissions; early detection and intervention of in-home supports will reduce demand for LTCHs

Risks:

• High cost to implement

• Lack of health human resources 5. Health Human Resources Context:

• Lack of trained staff with the skills and knowledge to accurately assess the frail elderly population • Lack of geriatricians, family physicians, psychogeriatric specialists, and registered staff across

the LHIN

• Shortage of health human resources at all levels across the Central East LHIN • Evaluation of dementia care training has reported strong uptake but insufficient integration due

to staffing/turnover issues

• Wage disparity between community-based providers and equivalent positions in LTCHs which impacts recruitment and retention in the community

Recommendations:

40. Develop a Health Human Resources Strategy including professional education as

a critical enabler for all of the ALC Task Group recommendations.

41. Develop a comprehensive training program for long-term care health care providers in

conjunction with academic institutions; utilize new graduates and late career initiatives to

enable new nurses to increase skills; increase number of Geriatric Nurse Specialists.

42. Continue enhanced skills training for both Registered and non-Registered staff in LTCHs

(program received recognition at Celebration Innovations in Health Care Expo 2007 and 2008).



43. Build on PIECES and U-FIRST training; dedicate staff positions within LTCHs to implement.

44. Hire Nurse Practitioners to work in conjunction with Medical Directors in LTCHs.

45. Implement investments in Ontario Telemedicine Network sites (new and existing) to increase

access to consultation with specialized resources (such as GEM nurses, geriatricians, psychogeriatric specialists).

46. Work with HealthForceOntario Strategy to promote jobs (education, funding, mentoring) in long term care field.

47. Develop strategy to recognize and value the role of Personal Support Workers and attract more people to the field.

48. Revamp Personal Support Worker curriculum to include skill levels required for Attendant Care and supportive housing services.

Benefits: • Education programs that promote profession • Adequate health human resources

Risks:

• Shortage of trained health care professionals can lead to barriers to discharge; reduced

system capacity

6. ALC System Monitoring and Evaluation Monitor and track ALC performance measures for system evaluation and planning Context:

• Poor ALC data quality – inaccurate and unreliable; not enough detail for effective planning • The ALC definition only applies to acute care and not other levels in the hospital (e.g. patient

is in a rehabilitation bed waiting for home care with supports but not documented as an ALC) so the data collected is often inaccurate

• Real-time current data difficult to collect

• Lots of information and reports on ALC issues; limited data on successful, evidence-based solutions



Recommendations: 49. Collect and track ALC information for local analysis and planning on monthly basis

(utilize Emergency Department Reporting System (EDRS) and ALC Census data).

50. Central East LHIN to undertake a Research Study to determine the percentage of

hospital patients waiting for a LTCH placement that could potentially receive the

most appropriate level of care in-home (own home, retirement home, supportive

housing) if enhanced community supports were available and affordable. (This

research study could be linked to an evaluation of the impact of the new initiatives to build community capacity through the three year Aging at Home Strategy initiatives and utilize the Balance of Care model that has been successfully demonstrated in other LHINs.)

51. Create a Central East LHIN ALC Implementation Committee to oversee and monitor

implementation of the approved recommendations and to track data for planning purposes

(and support evidence-based decisions on where to invest resources for most impact).

52. Implement a standardized database for ALC designations and discharge destinations (such as

Medworxx/Med Continuum that has been successfully implemented in 25 acute care hospitals in New Brunswick).

Benefits: • Create a comparable clinical, administrative, resource database across sites • Supports quality of care and benchmarking for best practices

• Shared understanding of “true” ALC pressures because data collection and tracking will include ALC patients in acute beds plus ALC patients in rehab, CCC, LTC beds

Risks: • Time and cost to build an information system • Requires buy-in from all stakeholders



Summary The ALC Task Group jointly support and endorse the findings and recommendations outlined in this report

and believe that it accurately reflects the ALC situation in the Central East LHIN. The mandate of the ALC Task Group was time-limited; however, addressing the ALC pressures will

require a sustained effort over several years. The recommendations in this report provide a framework for implementation and should be considered a starting point, not an end point, for better outcomes for clients/patients.

Continuous monitoring and tracking the performance outcomes will assist the hospitals in the Central East LHIN to reduce wait times in the Emergency Departments and to provide acute care to those who need it.

It will also help inform the Central East LHIN in determining where to invest resources to achieve results. Implementation of the recommendations will help to reduce ALC days and improve patient flow across

the system so that patients like Mr. Smith (see below) will have timely access to the appropriate level of care that they need. Returning home must be the first alternate level of care option of choice, whenever possible.

ALC remains a complex, serious system issue that impacts patient access to care, patient safety, and patient quality of life. Although ALC was initially identified as a hospital challenge to “fix”, there is no

one solution or one health provider that can repair the system. Eliminating ALC will require policy-makers, planners, funders, hospitals, physicians, community service providers, and residents and their families to work together with a shared understanding to achieve our vision for:

Right Care, Right Place, Right Time

Mr. Smith’s Story Mr. Smith is an 85 year old married man who was admitted to hospital after having been found unresponsive on the floor by his

family. While Mr. Smith was waiting in ER, the Geriatric Emergency Management (GEM) Nurse completed a geriatric assessment.

A risk screening assessment identified that Mr. Smith could be at risk of becoming “ALC” while in hospital. Therefore, immediate

referrals were made to the physiotherapy team for cognitive testing and physical activity. A series of tests were carried out that

initiated treatment for an infection that may have been contributing to the increasing cognitive and functional difficulties.

While Mr. Smith was still in ER, the Social Worker focused on the caregiver burnout reported by the family and explored

community caregiver supports to be used in addition to the maximum CCAC hours Mr. Smith was already receiving at home.

Mr. Smith followed a recommended routine while in hospital that included personal care and rehabilitation activities. The Social

Worker and Physiotherapist team recommended convalescent care upon discharge with follow-up in the geriatric clinic. Mr.

Smith and his family agreed and applications were made. He was discharged to a convalescent care bed in a local LTCH the next

day. The link to CCAC and community resources (including caregiver supports) was initiated prior to Mr. Smith’s discharge home

2 weeks later.



Implementation Action Plan Following a priority setting process the ALC Task Group highlighted thirteen recommendations as

highest priority for immediate implementation to achieve high impact results in the shortest timeframe. With Central LHIN approval and adequate resource allocation and endorsement from the hospitals, Central East CCAC, long-term care homes and community service providers; these recommendations are expected

to reduce ALC volumes by 10% in the first year of implementation.

RECOMMENDATION

RATIONALE

IMPACT/POTENTIAL

MEASURES

IMPLEMENTATION

(who, how)

RESOURCE

REQUIREMENTS

Risk Identification and Early Intervention

1. Utilize standardized risk screening and assessment tools in ED for the early identification of people in Emergency Department at high-risk for “failure to cope” or a “medically unnecessary” admission; facilitate early intervention of community supports

• standardized approach ensures consistent practice; supports patient/family expectations

• promotes early involvement of community supports and connections to maintain people at home

• reduce/prevent ED revisits

• avoid/delay admission

High impact – improved coordination between hospital and community services; shared responsibility to support high-risk clients; advance planning for potentially complex discharge will prevent and/or decrease the # of ALC days

Hospitals - emergency departments and acute care; Screeners may be GEM Nurse, ER Coordinators, Discharge Planners, Social Workers, Case Coordinators, CCAC, OT/Physiotherapists

Risk screening and assessment tool to be determined

Community support services to assist in service planning

Buy-in from ED and hospital staff to apply risk screening and assessment at regular intervals

Risk Identification and Early Intervention

2. Provide specialized staff resources in each hospital ED to inform and support clients/families with regard to what community supports are available and how to access them (extended hours to cover days and evenings 7 days/week)

• Patient and families arrive at hospital in emotional distress 24/7; psychosocial issues and inability to cope – need to know what options are available in community and hospital

• Need for patient and families to understand what ALC designation is and the value of planning for the future

High impact – potential to delay or avoid hospitalization and improve patient flow 7 days per week; facilitating respite care for the caregivers in the community will help maintain people at home

Hospital emergency departments;

Social Workers/Discharge Planners to be available for extended hours to cover evenings and weekends

Cost to increase FTE hours and shift coverage



RECOMMENDATION

RATIONALE

IMPACT/POTENTIAL

MEASURES

IMPLEMENTATION

(who, how)

RESOURCE

REQUIREMENTS

Patient Flow and Communication

3. Create and implement a Central East LHIN standard policy framework for the management of ALC issues including:

• Designation of ALC

• Co-payment initiation

• LTC choice list guidelines

• Principle of waiting in an out-of-hospital setting for LTCH bed

• “first available bed” procedures

• Actions responding to refusal of bed offers

• Standardize a consistent ALC Policy and its implementation across all

• Hospitals

• Develop a consistent triage/assessment process to delineate levels of care

• Improved ALC performance in hospitals; effective practice; more timely discharge

• Consistent messaging, similar ALC experiences for residents of Central East LHIN

• Common understanding of policies and practices throughout Central East LHIN

• Clear descriptions of care provided in LTCHs, CCC, rehab, etc. will assist in identifying most appropriate care level to meet need and improve discharge planning

• Standardized, reliable assessment tools will ensure most appropriate care

• Smoother transition across continuum of care

High impact

• Apply knowledge from Patient Flo Collaborative

• Streamline movement through hospital and improve capacity for acute care through single coordinating mechanism

• Appropriately match needs to alternate level of care – reduce transfer from designated ALC bed to “other” ALC bed

• Clear roles, shared expectations and accountability; improved coordination between hospital and community for quality patient care

• Set benchmarks for patient flow; utilize information systems to track

Hospitals

Expand Patient Flo Collaborative models to all hospitals

CEEC to develop ALC Policy

Framework

Central East LHIN ALC Implementation Committee (new)

Buy-in from hospital administration and physicians, CCAC

4. Expand definition and recognition of ALC beyond acute care bed spaces to include all patients waiting in post-acute beds for an alternate level of care

• Accurate estimation of numbers and types of ALC cases and real-time pressure points in Central East LHIN in determining actions to alleviate ALC issues

• Share data to support collaborative planning among hospitals, CCAC, community

High impact – improved ability to support system management and planning for all ALC patients; ability to target investments for highest impact

Central East LHIN Hospitals

Canadian Institute for Health Information’s Discharge Abstract Database

IT systems to be upgraded; training re: new data fields

5. Provide in-hospital activation/exercise program to maintain optimal functionality and mental wellness

• Reduce by 34-50% the number of in-patient seniors who experience functional decline and risk for institutionalization

High impact – preventable; stops permanent loss in ability to perform basic tasks of daily living; continued independence for person

All Central East LHIN hospitals to establish activation programs

Review existing models; may use trained volunteers, create policy



RECOMMENDATION

RATIONALE

IMPACT/POTENTIAL

MEASURES

IMPLEMENTATION

(who, how)

RESOURCE

REQUIREMENTS

System Access and Smooth Transitions Across Continuum of Care

6. Review the capacity of various funding models to increase the availability of housing by using retirement homes and/or supportive housing respite beds to offer enhanced care for ALC patients with light to medium level of care needs

Improves patient flow and moves people out of acute care while maintaining supports

Mobilization and activation may improve functionality of person enough to return home.

High impact – this is a model that is implemented by Peterborough Regional Health Centre

Hospital and community working in partnership

Funding to subsidize housing options

7. Provide training and financial resources to encourage specialization to create Behavioural Support Unit(s) within LTC homes that include short-stay transitional beds for people with temporary cognitive decline and permanent beds for people with ongoing behavioural needs

• High percentage of ALC days are patients waiting for a LTCH and are refused access due to unpredictable or aggressive behaviour

• High and growing number of people with dementia or related diseases in Central East LHIN; improve patient flow by supporting “hard- to-serve”

• Improved coordination of care

High impact – appropriately match needs to alternate level of care – more timely discharge

LTCH is most appropriate level of care – specialized supports offers quality healthcare

Central East CCAC

LTCHs

Cost to enhance/increase number and train LTCH staffing; costs to make physical environment accommodations in LTCH

Community Capacity and In-Home Care

8. Develop an enhanced comprehensive community services discharge planning process for acute care patient screened for high-risk upon admission (or earlier)

• Reduce ER visits and avoid hospitalization

• Improved patient flow, more timely access to community supports

• Supports quality of life and independence in community

High impact – will decrease number of high-risk people presenting to hospital and reduce the number of ALC days post-acute

Central East CCAC

GEM Nurses

Hospital Discharge Planners

Common risk screening tool; clear communication processes

9. Increase community support services for in-home personal support, homemaking and caregiver respite

• Reduce ER visits and avoid hospitalization

• Supports quality of life and independence in community

High impact – community workers can monitor health of client/family and intervene early with additional supports to avoid loss of functionality

Central East CCAC

Central East LHIN

Community health and social service agencies

Link with Aging at Home Strategy new initiatives

Cost to ensure “basket of services” is accessible in all parts of Central East LHIN



RECOMMENDATION

RATIONALE

IMPACT/POTENTIAL

MEASURES

IMPLEMENTATION

(who, how)

RESOURCE

REQUIREMENTS

Health Human Resources

10. Develop a Health Human Resource Strategy including professional education as a critical enabler for all of the ALC Task Group recommendations

• Increasing demand for community services will require adequate numbers of qualified staff to provide services

High impact – increased utilization of Nurse Practitioners as adjuncts to Family Physician practices and in LTCHs; MOHLTC funding Nurses in LTCHs

Central East LHIN, links with HealthForce Ontario

Cost to increase number of staff; remunerate qualified staff, provide training

ALC System Monitoring and Evaluation

11. Central East LHIN to undertake a Research Study to determine the %age of ALC patients waiting for a LTCH placement that could receive most appropriate care at home if enhanced community supports available/ affordable

• Effectively measure system performance for quality improvements

• Can set evidence-based system goals

• Reduced wait times

High impact – with data consistency can set benchmarks for standard wait times and discharge disposition

EDRS

eHealth Strategy

Central East LHIN

Hospitals

LTCHs, Rehab, CCC, CCAC

Balance of Care methodology

Cost to implement study

12. Create a Central East LHIN ALC Implementation Committee

• Initiate, oversee and monitor implementation of approved recommendations

• Experienced, committed ALC Task Group members to comprise core membership of new Committee insuring continued review, prioritizing and implementation of all recommendations

High impact – keeps current momentum going; track results, determine targeted investments for most impact

Central East LHIN

CEEC

CCAC

Must remain multi-stakeholder and include core group of current members to be successful in implementing change

Dedicated Project Coordinator/Manager position

The following recommendation is directed to MOHLTC for implementation:

13. Extend CCAC service maximums set by provincial regulation for nursing, home-making and enhanced personal support and the capacity for OT and physio to keep clients in their home as long as possible and to delay LTCH placement.

• Move people through hospital and out of ALC if appropriate level of care is available in home

• Earlier supports (pre-admission) will support continued independence and reduce hospital visits

High impact – keeping people healthy and well will reduce pressure on hospitals, reduce wait times in Emergency Department and improve quality of life and client satisfaction

MOHLTC

CCAC

Funding to CCACs to provide increased home care personal support and homemaking services



References 1. Acute Care Utilization Report: Central East LHIN, Health System Intelligence Project, March 2006.

2. OHA, OANHSS, OACCA, OLTCA ALC Working Group. Alternate Level of Care Challenges and

Opportunities, May 2006.

3. Report by the Expert Panel. Appropriate level of care: a patient flow, system integration and

capacity solution, MOHLTC, Dec. 2006.

4. Ottawa ALC Strategic Committee. From Alternate to Appropriate Levels of Care, Aug. 2006

5. Graf, C. Functional decline in hospitalized older adults. AJN 2006;106 (1): 58-67.

6. Can Assoc. of Emergency Physicians and the National Emergency Nurses Affiliation. Access to

acute care in the setting of emergency department overcrowding . Can J of Emergency Medicine 2003; 5(2): 81-86.

7. GTA Rehab Network. Analysis of Alternate Level of Care (ALC) Snapshots: Patients Awaiting Rehabilitation in ALC and Inpatient Rehab Capacity, May 2004.

8. GTA Rehab Network. Beyond Acute Care: Next Steps in Understanding ALC Days, March 2008.

9. Health Services Restructuring Commission. Change and Transition: Planning Guidelines and

Implementation Strategies for Home Care, Long Term Care, Mental Health, Rehabilitation, and Sub-acute Care. April 1998.

10. Hollander Analytical Services. The National Evaluation of the Cost-Effectiveness of Home Care, University of Victoria Centre on Aging. Retrieved April 30, 2008 from http://www.homcarestudy.com/reports/factsheets/NA101-01-Fact.html.

11. King, B. Functional decline in hospitalized elders. Medsurg Nursing 2006; 15(5): 265-271.

12. MOHLTC & Ontario LHINs. Ethical Issues of Access for Patients Requiring Long-Term Care Home Placement, Final Report. April 2008.

13. MOHLTC, Ontario’s Wait Time Strategy, May 2006.

14. North East LHIN ALC Task Force Report. A Review of Alternate Level of Care Pressures in North

East Ontario: findings and Recommended Strategies, December 2007.

15. OHA ALC Survey Results, February 2008.



16. Ostry, A. et al. Choosing a Model of Care for Alternate Level Care Patients: Caregivers’ Perspectives with Respect to Staff Injury, Can Journal of Nursing Research. In Press.

17. Report of the Physician Hospital Care Committee. Improving Access to Emergency Care:

Addressing System Issues, August 2006.

18. Caring for the Caregivers of “ALC”, Canadian Health Services Research Foundation, 2002, Ottawa.

19. Yassi, A. et al. Caring for the Caregivers of “Alternate Level of Care” Patients: The Impact of Healthcare Organizational Factors on Nurse Health, Well-being, Recruitment and Retention in the South Fraser Region of British Columbia. Canadian Health Services Research Foundation, April

2002, Ottawa.



Appendices: 1. ALC Task Group Terms of Reference 2. ALC Task Group Project Charter 3. Table of Central East LHIN Hospital Discharge Destinations 2006/07 4. Central East LHIN Demographics and Planning Zone Profiles



Appendix 1 Central East LHIN Alternate Level of Care Task Group Terms of Reference

Mandate Working in close partnership with the Central East LHIN, Central East LHIN providers, the Central East LHIN Seamless Care for Seniors Network, the Rehabilitation Task Group, and other planning partners, the ALC Task Group will assist in the implementation of the LHIN’s Integrated Health Service Plan (IHSP)

in the following manner: Conduct an environmental scan of Central East LHIN ALC pressures and existing practices that includes:

• Liaising with other provincial and regional ALC stakeholders in determining areas of leverage, including standardized definitions for levels of care, and evidenced-based best practices (joint undertaking with the Rehabilitation Task Force)

• Analyze/evaluate current incentives/disincentives and risks impacting ALC and person-centred care

• Review of relevant literature, provincial policy and regulations, and recent local investments

and innovations and their impact Prepare a Central East LHIN ALC Action Plan that includes:

• Common set of definitions • Suggested performance goals • Standardization of tools, best practices and innovations

• Recommendations regarding new or alignment of existing resources • Risk management strategies • Areas of future study

An analysis and recommendation directly related to long-term care, supportive housing, and home

care capacity/needs assessment is out of scope for this working group. However, it is anticipated that

the ALC Task Group and some of its members will evolve into a broader team examining LTC, supportive housing, and home care capacity.

Composition The ALC Task Group will be a committee of 15 individuals from across the LHIN that is reflective of:

• - the urban and rural diversity of the Central East LHIN

• - the range of relevant health care providers at the director/manager level, including: Central East LHIN community hospitals (8: 1/hospital corporation, with a mixture

representing CCC, rehab, mental health, patient flow)

Central East CCAC (2) Long-Term Care Homes, Supportive Housing,and Community Support Services (3 in total) Other (2: e.g., provincial associations, hard-to-place population)

ALC Task Group members must provide their services within the geographic boundaries of the Central East LHIN. The Central East LHIN is a culturally rich community, and has made capacity building in provision of culturally competent health care services a key priority.



ALC Task Group will be chaired by an individual selected by the Central East LHIN with input from the Central East LHIN Joint Executive Council (Hospitals and CCACs).

Commitment The ALC Task Group is time limited for a period of 6 months. This timeframe may be extended as needed.

Initial members must be prepared for a relatively intense commitment including, but not limited to, additional meetings as required, project tasks and additional voluntary assignments. Therefore, health service agencies/ organizations must actively support their representatives in fulfilling the roles and

responsibilities of the Task Group by allowing preparation for, and attendance at, multiple and perhaps additional meetings, fulfillment of project tasks and relevant contributions of other agency resources (e.g. data analysis) as required and appropriate. The Task Group will meet twice monthly using

face-to-face and tele- or videoconferencing formats.



Appendix 2 Central East LHIN Alternate Level of Care Task Group Project Charter

Project Background

The Alternate Level of Care (ALC) initiative is made possible through a collaboration of 15 host organizations and is organized through the Central East LHIN (CE LHIN). The project was initiated through the CE LHIN Central East Executive Council and is one of 4 task groups that are currently

working on enhancing patient flow through the various parts of the health care system.

Alternate Level of Care refers to individuals who occupy an acute care bed in hospital and no longer require acute care while waiting for an appropriate level of care.

The project is being driven by several components including: a. a desire to provide excellent care to all patients and prospective patients within

the CE LHIN geographic area;

b. the need to identify best practices to guide care for the ALC patient group; c. health economics; and, d. the need to understand patient flow issues within the CE LHIN.

This project is particularly important for senior citizens (i.e. people over 65 years old), who make up 13% of the Ontario population. CE LHIN has the second highest percent of those over 65 in the province and

this group is growing at a disproportionately higher rate than the rest of the population, at 15.2% compared to 5.7% in the total population. The population most at risk for requiring ALC is over 75 and there is further disproportionate need for services of that group within the CE LHIN, as it is anticipated to double

in size over the next 10 years. There has been considerable study, review and knowledge exchange around the issues that contribute to

the ALC dilemma. According to the MOHLTC Expert Panel on ALC, ALC days reflect significant issues related to patient flow, access to care, system integration, availability of care and service options, system capacity and resources. Several task forces, including one commissioned by the Ontario Hospital

Association (OHA) and the other by the Ministry of Health and Long Term Care have produced recommendations that are in various stages of implementation.



Project Purpose

The purpose of this project is to achieve better outcomes for patients who are waiting for alternate levels of care in acute hospitals within the Central East

LHIN. These hospitals are: • The Scarborough Hospital (General and Grace sites); • Rouge Valley Health System (Ajax Pickering and Centenary sites);

• Lakeridge Corporation (Oshawa, Port Perry and Bowmanville sites); • Northumberland Hills Hospital; • Peterborough Regional Health Centre;

• Ross Memorial Hospital; • Haliburton Highlands Health Services (Haliburton and Minden) Uxbridge

Hospital will be included to the extent possible; and,

• Campbellford Memorial Hospital. This will be achieved by making recommendations that will improve the

transition of ALC patients to a more appropriate community or hospital setting. The goal is to reduce the number of days patients are designated ALC by 30% over 3 years.

Strategic Alignment

. This project has been recommended by the CE LHIN CEEC group who have identified that a key stressor in their [hospital is the number of patients waiting for ALC. They have requested that concrete and executable recommendations

be made that will improve the situation across the LHIN. There are also associated initiatives that are providing positive changes to

best practices in the care for the elderly that will mitigate the ALC issue. The Geriatric Nurse Practitioner (GEM) initiative suggests that this program results in a more positive experience for the elderly patient requiring an

emergency room visit. There are financial benefits as well. This initiative may well impact positively on the ALC issue.

There is also considerable work being completed on the internal flow of patients as they move through the hospital system from emergency to discharge. This project is well-positioned to influence the newly announced Flo Collaborative:

Quality Transitions for Better Care, which is examining targeted improvements to patient flow and the transition from acute care facilities to the community through an 18-month action based learning collaborative. The CE LHIN ALC

Task Force will be the conduit in communicating information to all hospitals within the CE LHIN regarding the Flo Collaborative initiatives as it progresses.

ED Task Group, Rehab Task Group and eHealth Steering Committee



Project Benefits

1. Patients will receive timely service in the ‘right place’ at the ‘right time’.

2. A standardized definition of ALC will provide an ability to collect better data and in doing so, gain a better understanding of the issue.

3. The model will provide a ‘best practice’ template across the LHIN but will also be adaptable to the culture and structure of individual settings.

4. The best practice model will enhance system integration as the patient moves across the continuum of care

5. The project will help the CE LHIN with the ‘wait time’ strategy

as hospital beds will be available for acute care procedures. 6. The project will provide synergy and strength to the other

projects currently under way across the LHIN and will

contribute to “Seamless care for Seniors” activities.

Goals Objectives/Deliverables Performance Measures 1. Project initiation a. Determine the project

management strategy (how will the team go about completing

the project) b. Form an inter hospital, inter

agency team that recognizes the

strengths of all participants c. Bi weekly participation from the

large group and active

participation by sub groups

• Written Project Charter completed

• Broad membership from

senior managers from hospital, CCAC, long-term care, community

agencies • Create meeting schedule,

monitor attendance and

ensure an agreed upon attendance rate is followed.

2. Create an action plan by March 30, 2008 to reduce real ALC days by 30% by

December 10, 2010

Identify recommendations for implementation by ALC Implementation Task Group that will

be created by LHIN a. Development of environmental

scan

b. Review literature c. Review Best Practices d. Identify challenges and

opportunities for improvement Draft recommendations and implementation plan

• Track progress of each of these tasks

• Environmental Scan

completed • Literature review completed • Best practices identified

• Recommendation

and implementation

plan completed



Project “IN” & “OUT” of Scope Items

“IN” Scope “OUT” of Scope • Develop recommendations for strategies to improve

the transition of ALC patients to a more appropriate community or hospital resource by March 2008.

• To develop an understanding of the hospital and

community process issues that contributes to barriers and delays of transfers.

• Develop an understanding of previous work that

has been completed on this issue by other groups. • Develop a common understanding of the current

data that examines available versus best choices

for clients. • Develop an understanding of where the greatest

needs for intervention lie.

• Develop understanding of available new technology that might support change management process including eHealth strategies.

• Develop and understand an environmental scan.

• Implementation of recommendations that

are developed • Provide critique of previous reports

Project Timelines

High-Level Milestones Target Completion Dates • ALC Task Group is formed • Defined Vision and Mission Statement • Literature Review completed

• ALC Hospital Data Review completed • Project Charter completed • Development of Patient Process Flow

• Develop Recommendations and Implementation Plan

• May 2007 • June - July 2007 • July 2007

• July - September 2007 • September 2007 • September 2007

• December 2007



Project Partners

Partners Common Interests & Priorities Roles & Responsibilities CE LHIN All hospitals within CE LHIN CE Community Care Access

Centre (CCAC) Community support agencies: Canadian Red Cross –

Community Health Services Victorian Order of Nurses St. Joseph’s at Fleming LTCH

Kawartha Participation Projects Community Living Kawartha Lakes

Omni Healthcare Ltd.

• Charged with overall responsibility of improving basket of services for seniors

• Coordination of care for Rehab patients

• Success will be contingent on the buy in of staff and physicians in hospitals and also within community agencies

• Support of recommendations as part of the larger context

• Coordination of recommendation from all TG reports

• Communication and education strategy

Project Stakeholders

Stakeholders Interests & Needs Management Strategies • The citizens of the CE LHIN

that require either acute care or community based services

• Staff and physicians within all of the hospitals and community agencies

• CE LHIN Seamless Care for Seniors Network

• Rehab task force

• Mental Health and Addictions task force

• ED Task Force

• Our community needs to know that they will have access to acute care when they need it

• Our community has a right to be supported for their care in the most optimal setting

• This group is responsible for the ‘basket of services’ for seniors across the continuum

• Regular communication and updates to relevant parties as to the progress of the work of the committee

• Each task force member is responsible for ensuring that communications are taking place within their own organizations and across sectors

• Six month post report evaluation release re communication strategy from each task force member



Other Related Projects & Initiatives

Project/Initiative Interdependency & Impact • CE LHIN Emergency

Department Task Group, Flo initiatives, Seamless Care for Seniors Network

• The LHIN Emergency Department Task group is the task force that is

reviewing emergency access. The ALC issue impacts on this as ED beds are not accessible for patients that need to be admitted because they are being utilized by ALC patients.

• The Flo Collaborative initiative is provincially mandated and provides selected hospitals the opportunities to study their patient flow and make appropriate changes.

• The Aging at Home Strategy is funding new/enhanced community support initiatives that will potentially delay admission to Long Term Care Homes and free up appropriate ALC placement.

People & Organization Change Impacts

Description of Impact Impact Management Strategies • A reduction in ALC patients will impact the day to day work

of hospital staff as they are better able to utilize their beds

for acute care patients. This may mean that their workloads increase as they are looking after more acutely ill patients.

• Increased utilization of beds through increased patient flow

and therefore decreasing ‘wait time’ in emerg and/or for elective procedures

• Early identification and intervention with patients at high-

risk to become ALC will delay premature admission to long-term care homes

•

Project Communications

Audience Information Needs Format & Timing Responsible

• CEO’s and senior

staff of hospitals • Staff of host

organizations

• To provide realistic understanding of

scope of this project and the impact of implementation on host organizations

• To facilitate staff’s understanding of the changes that are required

• October

(via LHIN staff) • Final report

Dec/Jan

• LHIN and

Task Group



Project Risks

Risk Likelihood Impact Risk Response

• This issue has been studied in depth and many recommendations have

been made. Some have been implemented with success. This project may have difficulty coming up

with new recommendations that are sustainable over the long term

• Moderate • High • Ensure that the recommendations

are PRACTICAL

• The recommendations do not result in buy-in from some or all of the affected organizations.

• Moderate • High • Incorporate stakeholder participation/feedback to develop recommendations.

Critical Success Factors

• Must be in alignment with other initiatives including the ED and GEM task forces, and the MHA and

Seamless Care for Seniors Steering committee • Participation of all stakeholders. • Receptivity to change management process that will be required across all sectors of CE LHIN.

• Transparency and buy-in of stakeholders to make changes in timely manner and accept re allocations that may be required

Assumptions & Constraints

Assumptions Constraints • Once accepted by CE LHIN Board, our

recommendations will proceed to implementation across LHIN

• The recommendations will be followed by the Implementation Committee

• Recommendations must not assume availability of additional funding

• There are legislative constraints that may

impact on our ability to make recommendations

• Our recommendations may not be a priority

for all organizations



Appe

ndix

3 Ta

ble o

f Hos

pita

l Disc

harg

e Des

tinat

ions

06/0

7



Appe

ndix

4 Ce

ntra

l Eas

t LHI

N De

mog

raph

ics an

d Pla

nnin

g Zon

e Pro

files



ALC in each Central East LHIN Planning Zone In reviewing the most current available data, the ALC pressures and the hospital and community services

vary across each of the nine Central East planning zones, which are further examined in more detail below. All hospital and ALC data must be interpreted with caution. The specific number of beds by type may

change over time and may be slightly different depending on year and data source. The ALC data is from the Provincial Health Planning Database. Data for the number of Long-Term Care Home beds and convalescent care beds was provided by the Central East Community Care Access Centre. The human

resource data was provided by the Central East LHIN. Durham Region Durham Region encompasses three Collaboratives in the Central East LHIN; Durham East, Durham West, and Durham North/Central. In 2001, there were 494,901 residents including 49,645 over the age of 6514. Durham North/Central has the lowest percentage of people with low income in the Central East LHIN.

In total, there are 780 Family Physicians and 18 Nurse Practitioners. Acute care hospital services are provided by the Lakeridge Health Corporation (Oshawa, Bowmanville, Port Perry sites) Rouge Valley

Health System – Ajax Pickering site, and Markham Stouffville Hospital Uxbridge site with a total of 798 acute care beds.

In 2006/07, the Lakeridge Health Corporation (337 acute care beds in three sites) had a total of 1,306 people designated ALC with an accumulated total of 15,470 days waiting. Lakeridge Health Corporation has 31 chronic care beds and 49 general rehabilitation beds at its Oshawa site and another 65 chronic care

beds at its Bowmanville site.

In 2006/07, the Rouge Valley Health System Ajax site had 104 acute care beds, 10 chronic care beds and

8 general rehabilitation beds. A total of 299 people were designated ALC throughout the year. In 2006/07, the Markham Stouffville Hospital Uxbridge site (20 acute care beds) had a total of eleven

people designated ALC with an accumulated total of 63 days waiting. The Durham region has a total of 2,780 LTCH for-profit and non-profit beds including 11 short-stay and

17 convalescent care beds. Northumberland- Havelock The Northumberland planning zone is largely rural and hosts the Northumberland/Havelock Collaborative. In 2001, there were 72,527 residents including 12,850 over the age of 65 (18% of the total population). It has the highest percentage of the population whose mother tongue is English in all of the Central East LHIN.

In total, there are 109 Family Physicians and 0 Nurse Practitioners. Acute care hospital services are provided by the Northumberland Hills Hospital (Cobourg) and Campbellford Memorial Hospital with

a total of 109 acute care beds.

14 All population data is based on the 2001 Statistics Canada Census and information from the CE LHIN Planning Zone Profiles.



In 2006/07, Northumberland Hills Hospital (75 acute care beds) had a total of 313 people designated ALC with an accumulated total of 5,306 days waiting. Northumberland Hills also has 7 chronic care

beds and 18 general rehabilitation beds. In 2006/07, the Campbellford Memorial Hospital (34 acute care beds and 10 chronic care beds) had a total

of seventy-three people designated ALC with an accumulated total of 4,890 days waiting. The Northumberland-Havelock area has a total of 678 LTCH for-profit and non-profit beds including

8 short-stay and 0 convalescent care beds. The total LTCH beds includes 11 interim LTCH beds which are defined as temporary beds only made available to ALC clients. City of Peterborough and County Peterborough and its’ surrounding area is one Central East LHIN planning zone and hosts the Peterborough City and County Collaborative. There were 121, 377 residents in 2001 and 21,770 were

over 65 years old; 18% of the total population. It has the highest number of Aboriginal people in the Central East LHIN.

In total, there are 348 Family Physicians and 11 Nurse Practitioners. Acute care hospital services are provided by the Peterborough Regional Health Centre with a total of 273 acute care beds, 28 chronic care beds and 28 general rehabilitation beds.

In 2006/07, the Peterborough Regional Health Centre had a total of 321people designated ALC with an accumulated total of 9,586 days waiting.

The Peterborough area has a total of 1,129 LTCH for-profit and non-profit beds including 8 short-stay and 10 convalescent care beds and 23 interim beds.

Kawartha Lakes The City of Kawartha Lakes is one planning zone and hosts one Collaborative. Of its 69,179 residents in

2001, 19% (13,175) were age 65 and over. There are 109 Family Physicians and 3 Nurse Practitioners. Acute care hospital services are provided by the Ross Memorial Hospital (Lindsay) with a total of 113 acute care beds, 31 chronic care beds, 15 mental health and 16 general rehabilitation beds.

In 2006/07, the Ross Memorial Hospital had a total of 288 people designated ALC with an accumulated total of 6,285 days waiting.

The City of Kawartha Lakes area has a total of 740 LTCH for-profit and non-profit beds including 2 short-stay and 0 convalescent care beds.

Haliburton- Minden The Haliburton Highlands area is one planning zone and hosts one Collaborative. In 2001 it had 15,085

residents and the highest percentage of people age 65 and over (24%) in the Central East LHIN. It is also home to a high number of residents without a high school education (36%) and with a low income (13%).



There are 24 Family Physicians and 0 Nurse Practitioners. Acute care hospital services are provided by the Haliburton Highlands Health Services Corporation with a total of 14 acute care beds.

In 2006/07, the Haliburton Highlands Health Service Corporation had a total of 11 people designated ALC with an accumulated total of 366 days waiting.

The Haliburton Highlands and Minden area has a total of 152 LTCH for-profit and non-profit beds including 1 short-stay and 0 convalescent care beds.

Scarborough The Scarborough planning zones in the Central East LHIN are markedly different than the rest of the

region. There are two Collaboratives, the Scarborough Agincourt-Rouge and the Scarborough Cliffs-Centre and a total population of 561,948 in 2001 that included 71,590 residents (12.7%) over age 65. It has the highest per cent of the population with no knowledge of French or English (6% versus 2% in Ontario); the

highest per cent immigrant population (12% versus 5% in Ontario) and the highest per cent of new immigrants (56% versus 27% in Ontario). These two planning zones also have over 20% of the population living in low income.

In total, there are 1,027 Family Physicians and 0 Nurse Practitioners. Acute care services are provided by Rouge Valley Health System (Centenary site and Ajax-Pickering site) and The Scarborough Hospital

(General site and Grace site). The Rouge Valley Health System Centenary site has 198 acute care beds, 54 chronic care beds and 32

general rehabilitation beds. The Scarborough Hospital General site has 305 acute care beds, 0 chronic care beds and 11 general

rehabilitation beds; the Grace site has 189 acute care beds, 0 chronic care beds and 10 general rehabilitation beds.

In 2006/07, the The Scarborough Hospital had a total of 324 people designated ALC at the General site and another 202 people designated ALC at the Grace site with an accumulated total at both sites of 10,738 days waiting for an alternate level of care.

The Scarborough area has a total of 4,093 LTCH for-profit and non-profit beds including 33 short-stay and 48 convalescent care beds.

alternate level of care systems issues and recommendations

Documents