Strategies to Reduce Alternate Level of Care in Canadian Hospitals

A new Environmental Scan from Canada’s Drug Agency examines Canadian data related to alternate level of care (ALC) and the effectiveness of strategies health systems use to reduce ALC times.

ALC is a designation that refers to people who occupy a hospital bed, but who don’t require the intensity of resources or services provided in hospital. It is a persistent barrier to delivering efficient health care in Canada, as it is in many global health systems (where it is called delayed discharge).

A high volume of patients in ALC means fewer beds are available for new patients and contributes to emergency department overcrowding. It can also delay treatment for incoming patients and strain health care workers who are managing patients who are acute and nonacute. Patients and caregivers also report poor experiences with ALC, including confusion, stress, uncertainty, and frustration.

The largest subgroup of people in ALC in Canada is older adults (65 years and older) who are waiting for placement in residential care. Other individuals in ALC may be waiting for space in a rehabilitation centre or hospice or for homecare and community supports.

Characteristics of Patients in ALC

We analyzed data from the Discharge Abstract Database at the Canadian Institute for Health Information and found that at least 70% of ALC days across jurisdictions were from patients aged 75 years and older. We also found the majority of patients in ALC started as an urgent admission (86%). Our report presents the key characteristics of older patients with an ALC designation, which can help clinicians and decision-makers identify those who are at risk of ALC.

Strategies to Address ALC

In our literature review, we identified 19 strategies that address or have been effective in reducing ALC among older adults in Canada. The report organizes the strategies along the continuum of input, throughout, output, and system-level strategies.

Our analysis shows that 2 throughput strategies — a subacute care unit for older patients who are frail and a transitional care unit — improve discharge to home. Further, 2 system-level strategies — Home First and Behavioural Supports Ontario — improved ALC hospitalizations and length of stay.

Informing Decisions About ALC

In a new project, Canada’s Drug Agency will build on the findings of our Environmental Scan to support jurisdictions in their policy decisions around ALC challenges. The new project also builds on recent evidence and guidance we’ve delivered on the related systems-wide challenges of emergency department overcrowding and aging in place.

As part of this work, we aim to:

• identify and describe the most relevant reasons people in Canada are designated to ALC, describe the initiatives that are known to successfully address these reasons, and discuss considerations for the implementation of these initiatives
• provide trusted guidance to senior decision-makers to support evidence-informed and equitable initiatives to decrease ALC rates across jurisdictions in Canada.

Through an open call for statements of interest, we are looking to engage people with extensive personal or professional experience in this area. This includes clinicians, policy-makers, and people with direct, personal experience with the challenges and success factors of strategies to avoid or reduce ALC days (e.g., older adults, spouses, adult children or other family members, family caregivers).