Alternate Level Of Care Patients Research Articles

Short-term mortality and palliative care use after delayed hospital discharge: a population-based retrospective cohort study

ObjectivesIn Canada, patients whose acute medical issues have been resolved but are awaiting discharge from hospital are designated as alternate level of care (ALC). We investigated short-term mortality and palliative...

What Factors Increase Odds of Long-Stay Delayed Discharge in Alternate Level of Care Patients?

The objective of this study was to determine the factors that increase the odds of long-stay delayed discharge in alternate level of care (ALC) patients using data collected from the Ontario Wait Time Information System (WTIS) database. Retrospective cohort study utilizing data from Niagara Health's WTIS database. WTIS includes individuals admitted to any of the Niagara Health sites that have been designated as ALC. Sample consisted of 16,429 ALC patients who received care in Niagara Health hospitals from September 2014 to September 2019 and were recorded in the WTIS database. ALC designation of 30 or more days was used as the threshold for a long-stay delayed discharge. This study used binary logistic regression modeling to analyze sex, age, admission source, and discharge destination as well needs/barriers requirements to assess the likelihood of a long-stay delayed discharge among acute care (AC) and post-acute care (PAC) patients given the presence of each variable. Sample sizes calculations and receiver operating characteristic curves were used to verify the validity of the regression model. Overall, 10.2% of the sample were considered long-stay ALC patients. Both AC and PAC long-stay ALC patients were more likely to be male [OR= 1.23, (1.06-1.43); OR= 1.28, (1.03-1.60)] and have a discharge destination of a long-term care bed [OR= 28.68, (22.83-36.04); OR= 6.22, (4.75-8.15)]. AC patients had bariatric [OR= 7.16, (3.45-14.83)], behavioral [OR= 1.89, (1.22-2.91)], infection (isolation) [OR= 2.31, (1.63-3.28)], and feeding [OR= 6.38, (1.82-22.30)] barriers hindering discharge. PAC patients had no significant barriers hindering patient discharge. Shifting the focus from ALC patient designation to short- vs long-stay ALC patients allowed this study to focus on the subset of patients that are disproportionately affecting delayed discharges. Understanding the importance of specialized patient requirements in addition to clinical factors can help hospitals become more prepared in preventing delayed discharges.

The cost-effectiveness of a nursing home-based transitional care unit for increasing the potential for independent living in the community among hospitalized older adults

ObjectiveIn Canada, a persistent barrier to achieving healthcare system efficiency has been patient days accumulated by individuals with an alternate level of care (ALC) designation. Transitional care units (TCUs) may address the capacity pressures associated with ALC. We sought to assess the cost-effectiveness of a nursing home (NH) based TCU leveraging existing infrastructure to support a hospitalized older adult’s transition to independent living at home.MethodsThis case-control study included frail, older adults who received care within a function-focused TCU following a hospitalization between 1 March 2018 and 30 June 2019. TCU patients were propensity score matched to hospitalized ALC patients (“usual care”). The primary outcome was days without requiring institutional care six months following discharge, defined as institutional-free days. This was calculated by excluding all days in hospitals, rehabilitation facilities, complex continuing care facilities and NHs. Using the total direct cost of care up to discharge from TCU or hospital, the incremental cost-effectiveness ratio was calculated.ResultsTCU patients spent, on average, 162.0 days institution-free (95% CI: 156.3–167.6d) within six months days post-discharge, while usual care patients spent 140.6 days institution-free (95% CI: 132.3–148.8d). TCU recipients had a lower total cost of care, by CAN$1,106 (95% CI: $–6,129–$10,319), due to the reduced hospital length of stay (mean [SD] 15.6d [13.3d] for TCU patients and 28.6d [67.4d] days for usual care). TCU was deemed the more cost-effective model of care.LimitationsThe main limitation was the potential inclusion of patients not eligible for SAFE in our usual group. To minimize this selection bias, we expanded the geographical pool of ALC patients to patients with SAFE admission potential in other area hospitals.ConclusionsThrough rehabilitative and restorative care, TCUs can reduce hospital length of stay, increase potential for independent living, and reduce risk for subsequent institutionalization.

Healthcare-Associated Adverse Events in Alternate Level of Care Patients Awaiting Long-Term Care in Hospital.

Introduction: A growing number of Canadian older adults are designated alternate level of care (ALC) and await placement into long-term care (LTC) while admitted to hospital. This creates infrastructural challenges by using resources allocated for acute care during disproportionately long hospital stays. For ALC patients, hospital environments maladapted to their needs impart risk of healthcare-associated adverse events. Methods: In this retrospective descriptive study, we examined healthcare-associated adverse events in 156 ALC patients, 65 years old and older, awaiting long-term care while admitted to two hospitals in London, Ontario in 2015–2018. We recorded incidence of infections and antimicrobial days prescribed. We recorded incidence of non-infectious adverse events including delirium, falls, venothrombotic events, and pressure ulcers. We used a restricted cubic spline model to characterize adverse events as a function of length of stay. Results: Patients waited an average of 56 ALC days (ranging from 6 to 333 days) before LTC placement, with seven deaths occurring prior to placement. We recorded 362 total adverse events accrued over 8668 ALC days: 94 infections and 268 non-infectious adverse events. The most common hospital-acquired infections were urinary-tract infections and respiratory infections. The most common non-infectious adverse events were delirium and falls. A total of 620 antimicrobial days were prescribed for infections. Conclusions: ALC patients incur a meaningful and predictable number of adverse events during their stay in acute care. The incidence of these adverse events should be used to educate stakeholders on risks of ALC stay and to advocate for strategies to minimize ALC days.

The emergence of the physician assistant role in a Canadian acute care surgery setting

The role of physician assistants (PAs) in surgical care in Canada is expanding. Similarly, the acute care surgery (ACS) model continues to evolve, and PAs are increasingly being considered as members of ACS teams. However, their exact impact and contribution has not been well studied. Our study describes the contribution of a PA who worked full time on weekdays on an ACS team in a Canadian academic tertiary hospital. To quantify the PA's contributions, an ACS database was created in September 2016. Data on the number of ACS patient encounters, the number of ACS surgical consults, the number of ACS admissions, the PA's involvement in the operating room, the number of PA patient encounters and the number of multidisciplinary meetings were prospectively collected. We report data for 365 consecutive days from Dec. 30, 2016, to Dec. 29, 2017. The ACS team had 11 651 patient encounters during the year, with a mean of 31.92 per day. The mean number of surgical consults per day was 5.89, and a mean of 2.08 surgical procedures were performed per day. The PA was involved in 53.5% of all patient encounters, despite working only during daytime hours on weekdays. Multidisciplinary meetings were conducted by the PA 94.9% of the time. Alternate level of care patients were seen by the PA 96.2% of the time. The PA was directly involved in 2.0% of the operating room procedures during the study period. Integrating a PA on an ACS team adds value to patient care by providing consistency and efficient management of ward issues and patient care plans, including multidisciplinary discharge planning, timely emergency department consultations and effective organization of the ACS team members.

The Post-Acute Delayed Discharge Risk Scale: Derivation and Validation With Ontario Alternate Level of Care Patients in Ontario Complex Continuing Care Hospitals

ObjectivesTo describe and validate the Post-acute Delayed Discharge Risk Scale (PADDRS), which classifies patients by risk of delayed discharge on admission to post-acute care settings using information collected with the interRAI Minimum Data Set (MDS) 2.0 assessment. DesignRetrospective cohort study of individuals admitted to Ontario Complex Continuing Care (CCC) hospitals. Person-level linkage between interRAI MDS 2.0 assessments and Cancer Care Ontario Wait Time Information System records was performed. Setting and ParticipantsSample of 30,657 patients who received care in an Ontario CCC hospital and were assessed with the interRAI MDS 2.0 assessment between January 1, 2010, and March 31, 2013. MeasuresAlternate Level of Care (ALC) designation of 30 or more days was used as the marker of delayed discharge. Scale validation was performed through computation of class-level effect sizes and receiver operating characteristic curves for each of Ontario's geographic health regions. Additionally, Clinical Assessment Protocol (CAP) decision-support tool trigger rates by PADDRS risk level were computed for problem areas that are clinically relevant with the delayed discharge outcome. ResultsOverall, 9.4% of the sample experienced the delayed discharge outcome. The PADDRS algorithm achieved an overall area under the curve (AUC) statistic of 0.74, which indicates good discriminatory ability for predicting delayed discharge. PADDRS is generalizable across geographic regions, with AUC statistics ranging between 0.61 and 0.81 across each of Ontario's 14 Local Health Integration Networks. PADDRS demonstrated strong concurrent validity, as the percentage of patients triggering CAPs increased with the risk of delayed discharge. Conclusions and ImplicationsPADDRS combines numerous important clinical factors associated with delayed discharge from a post-acute hospital into a cohesive decision-support tool for use by discharge planners. In addition to early identification of patients who are most likely to experience delayed discharge, PADDRS has applications in risk-adjusted quality measurement of discharge planning efficiency.

Risk factors, costs and complications of delayed hospital discharge from internal medicine wards at a Canadian academic medical centre: retrospective cohort study

BackgroundHospitalized patients are designated alternate level of care (ALC) when they no longer require hospitalization but discharge is delayed while they await alternate disposition or living arrangements. We assessed hospital costs and complications for general internal medicine (GIM) inpatients who had delayed discharge. In addition, we developed a clinical prediction rule to identify patients at risk for delayed discharge.MethodsWe conducted a retrospective cohort study of consecutive GIM patients admitted between 1 January 2015 and 1 January 2016 at a large tertiary care hospital in Canada. We compared hospital costs and complications between ALC and non-ALC patients. We derived a clinical prediction rule for ALC designation using a logistic regression model and validated its diagnostic properties.ResultsOf 4311 GIM admissions, 255 (6%) patients were designated ALC. Compared to non-ALC patients, ALC patients had longer median length of stay (30.85 vs. 3.95 days p < 0.0001), higher median hospital costs ($22,459 vs. $5003 p < 0.0001) and more complications in hospital (25.5% vs. 5.3% p < 0.0001) especially nosocomial infections (14.1% vs. 1.9% p < 0.0001). Sensitivity analyses using propensity score and pair matching yielded similar results. In a derivation cohort, seven significant risk factors for ALC were identified including age > =80 years, female sex, dementia, diabetes with complications as well as referrals to physiotherapy, occupational therapy and speech language pathology. A clinical prediction rule that assigned each of these predictors 1 point had likelihood ratios for ALC designation of 0.07, 0.25, 0.66, 1.48, 6.07, 17.13 and 21.85 for patients with 0, 1, 2, 3, 4, 5, and 6 points respectively in the validation cohort.ConclusionsDelayed discharge is associated with higher hospital costs and complication rates especially nosocomial infections. A clinical prediction rule can identify patients at risk for delayed discharge.

Medication Use by Alternate Level of Care Patients: A Descriptive Analysis

The population of patients designated as alternate level of care (ALC) consists predominantly of frail older adults who are medically stable and awaiting discharge from hospital. They have complex medication regimens, often including potentially inappropriate medications (PIMs). There has been increasing emphasis on managing the burden that ALC patients place on the health care system, but little is known about their health care needs. To characterize the medication regimens, including use of PIMs, of ALC patients at the study institution. A cross-sectional chart audit of ALC patients was conducted between May and July 2017. For all patients in the sample, each medication was categorized by therapeutic class, and PIMs were categorized according to the Beers criteria, the STOPP/START criteria, and an established list of high-alert medications. A total of 82 patients met the audit criteria, for whom the mean number of chronic conditions was 6.4 (standard deviation [SD] 3.3) and the mean number of prescribed medications was 12.8 (SD 6.9). Twenty-four (29%) of the patients were receiving at least 1 drug from 7 different drug classes. All but one of the patients had PIMs in their regimen; the frequency of PIMs was highest according to the Beers criteria (mean 3.9 [SD 2.6] medications per patient). At the study institution, ALC patients had on average more than 6 chronic conditions managed with at least 12 medications, of which one-quarter were PIMs. These data will be used to inform next steps in making recommendations to simplify, reduce, or discontinue medications for which there is an unclear indication, lack of effectiveness, or evidence of potential harm.

The Impact of Introducing Restorative Care on Client Outcomes and Health System Effectiveness in an Integrated Health Authority

To support the transition from hospital to community for adults 65 years and older, a restorative care unit was introduced within a regional health authority in Newfoundland and Labrador. A pre-post study design was used to evaluate the impacts of restorative care. This article describes the impact of restorative care on client outcomes and health system utilization. All patients discharged from restorative care during the first year of operation were included in the study. A total of 54 clients were discharged during the first year, with 70% being discharged to a community setting. Consistent with previous studies, statistically significant improvements were noted in function as measured using the modified Barthel Index of Activities of Daily Living and fear of falling as measured using the Fall Efficacy Scale–International. The number of alternate level of care patients in acute care and their length of acute care stay did not decrease during our study period. However, an interesting change was observed: The number of applications for long-term care initiated in acute care decreased. Further examination of the long-term outcomes of discharged patients and of the factors influencing health system outcomes is suggested.

P115: An analysis of current and forecasted patient visits to Ontario’s emergency departments and its effect on hospital admissions

Introduction: The number of emergency department (ED) visits across Ontario has increased annually over the past two decades leading to overcrowding and longer wait times. ED volume forecasting may provide insight to strategic planners regarding future patient volumes and the effects on health care resources. We investigated the pattern of ED use at the local health integration network (LHIN) level and developed forecasts using historical data. The forecasts were then used to examine the effect on acute care hospital bed requirements and the number of full time equivalent physicians needed. Methods: Aggregated data from the Canadian Institute for Health Information for the period 2003 to 2013 was obtained for each of Ontario’s LHINs. The total number of ED visits per year was first quantified by LHIN and then simple linear regression was used to forecast patient volumes in 2018 and 2023. The rate of hospital admission by LHIN was also calculated. We then used the forecasted volume, admission rate and the total number of acute care hospital beds by LHIN to predict the total number of beds needed by LHIN. Based on the forecasted patient volumes and the hours of coverage model, the total number of full-time equivalent physicians needed was calculated. Results: Over the study period, the number of patients increased from 4 to 37% among LHINs. Admission rates generally decreased from 2003 to 2013. Based on historical trends, all EDs across Ontario are expected to experience increased patient visits in the future but at different rates of growth. Depending on the rate of growth in ED visits, the number of acute care beds needed by LHIN is somewhat variable and affected by the proportion of alternate level of care patients. Given, the forecasted increase in patient volume, the hours of coverage model suggests that approximately 320 additional full-time equivalent ED physicians are needed across the province by 2023. Conclusion: Although all forecasts inherently have a degree of error associated with their estimates, strategic planners require some quantitative prediction of future events to develop initial plans. Through research, these predictions can be focused and refined. The results suggest that many hospitals will experience increased demand for services and will have to do resource allocation planning accordingly to ensure patient demand is met appropriately.

Determining the Public/Private Mix: Options for Financing Targeted Universality in Long-Term Care.

The way in which we pay for long-term care (LTC) services is going to come under enormous pressure as Canada's baby boomers age. Once baby boomers start to turn 75, in 2021, the demand for LTC services will see a sharp upward trend. A number of independent projections have demonstrated how this will put pressure on the public finances in coming years. It should be concerning to Canadians that we have not publicly discussed how we will make the tough choices to cope with these pressures. Moreover, it's equally troubling that our provincial LTC systems already are unable to cope with the current level of demand for services, with less than a decade before the first wave of boomers enter age groups where demand for LTC is high, and alternate level of care patients, made up mostly of frail elderly, occupying over 15% of Canadian hospital beds on a daily basis as they await care elsewhere. Although we think it is unlikely that Canadian provinces will add LTC to the list of fully subsidized health services (hospitals and doctors), we should do a better job of targeting the existing public subsidies for LTC - and do so while putting LTC financing on a more sustainable footing.

Application of the Beers Criteria to Alternate Level of Care Patients in Hospital Inpatient Units.

The Beers criteria were developed to help in identifying potentially inappropriate medications (PIMs) for elderly patients. These medications are often associated with adverse events and limited effectiveness in older adults. Patients awaiting an alternate level of care (ALC patients) are those who no longer require acute care hospital services and are waiting for placement elsewhere. They are often elderly, have complex medication regimens, and are at high risk of adverse events. At the time of this study no studies had applied the Beers criteria to ALC patients in Canadian hospitals. To determine the proportion of ALC patients receiving PIMs and the proportion experiencing selected PIM-related adverse events. A retrospective chart review of ALC patients 65 years of age or older was performed to identify PIMs and the occurrence of selected adverse events (specifically central nervous system [CNS] events, falls, bradycardia, hypoglycemia, seizures, insomnia, gastrointestinal bleeding, and urinary tract infections). A logistic regression model with a random intercept for each patient was constructed to estimate odds ratios and probabilities of adverse events. Fifty-two ALC patients were included in the study. Of these, 48 (92%) were taking a PIM. Of the 922 adverse events evaluated, 407 (44.1%) were associated with a regularly scheduled PIM. Among patients who were taking regularly scheduled PIMs, there was a significantly increased probability of an adverse CNS event and of a fall (p < 0.001 for both). The most common PIM medication classes were first-generation antihistamines (24 [46%] of the 52 patients), antipsychotics (21 patients [40%]), short-acting benzodiazepines (15 patients [29%]), and nonbenzodiazepine hypnotics (14 patients [27%]). A high proportion of ALC patients were taking PIMs and experienced an adverse event that may have been related to these drugs. These findings suggest that the ALC population might benefit from regular medication review and monitoring to prevent or detect adverse events.

ALC status in in-patient mental health settings: Evidence based on the Ontario Mental Health Reporting System.

This article examines the characteristics associated with Alternate Level of Care (ALC) status in mental health in-patient units across Ontario. Using assessment information from the Resident Assessment Instrument-Mental Health, the prevalence of ALC episodes, resource utilization associated with ALC, and demographic and diagnostic characteristics of ALC patients are examined. The effective management of ALC patients should be an important priority for all stakeholders involved in mental health services delivery in Canada.

Alternate level of care patients in hospitals: what does dementia have to do with this?

BackgroundPatients in acute care hospitals no longer in need of acute care are called Alternate Level of Care (ALC) patients. This is growing and common all across Canada. A better understanding of this patient population would help to address this problem.MethodsA chart review was conducted in two hospitals in New Brunswick. All patients designated as ALC on July 1, 2009 had their charts reviewed.ResultsThirty-three per cent of the hospital beds were occupied with ALC patients; 63% had a diagnosis of dementia. The mean length of stay was 379.6 days. Eighty-six per cent were awaiting a long-term care bed in the community. Most patients experienced functional decline during their hospitalization. One year prior to admission, 61% had not been admitted to hospital and 59.2% had had at least one visit to the emergency room.ConclusionsThe majority of the ALC patients in hospital have a diagnosis of dementia and have been waiting in hospital for over one year for a long-term care bed in the community. Many participants were recipients of maximum home care in the community, suggesting home maker services alone may not be adequate for some community-dwelling older adults. Early diagnosis of dementia, coupled with appropriate care in the community, may help to curtail the number of patients with dementia who end up in hospital as ALC patients.

Waiting for placement: Discharge from hospital to long-term care in Ontario

Great pressures are placed on hospitals to promptly discharge patients. This is especially true of patients deemed “alternate level of care,” often referred to pejoratively as “bed blockers.” To alleviate these pressures, hospitals enact policies, both formal and informal, to discharge alternate level of care patients who are awaiting placement into long-term care homes. In addition to being dangerous for some of the patients discharged, these discharge policies also leave the hospital, its employees, physicians, and Community Care Access Centres open to legal liability. In 2013, the Advocacy Centre for the Elderly received more than 300 individual requests for legal service in 2013 on behalf of patients, relating to conflict with hospital policies and the placement process. This article analyzes the legal requirements relating to discharge from hospital and admission to long-term care.

Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region

BackgroundAcute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission.MethodsPopulation-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days.ResultsALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27 day mean deviation, 99% CI = ±14.6), psychiatric diagnosis (13 day mean deviation, 99% CI = ±6.2), abusive behaviours (12 day mean deviation, 99% CI = ±10.7), and stroke (7 day mean deviation, 99% CI = ±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1st 2009 and April 1st, 2011. ALC patients with the identified characteristics had unique clinical profiles.ConclusionsA small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.

Clinical Characteristics and Service Needs of Alternate-Level-of-Care Patients Waiting for Long-Term Care in Ontario Hospitals

Alternate-level-of-care (ALC) patients waiting for admission to long-term care (LTC) in Ontario hospitals are an important subgroup of ALC patients. Understanding the characteristics of ALC patients waiting for LTC can identify opportunities for alternative discharge options. Characteristics from a sample of 13,915 ALC patients waiting for LTC in acute and complex hospitals were analyzed and compared to those from a sample of 113,046 long-stay home care clients in Ontario. Population-level data were obtained using Ontario's RAI-HC database for the period January 2007 to September 2008. Relative to older long-stay home care clients, ALC patients waiting for LTC admission have more functional impairment and complex health needs. A combination of targeted transitional care and more resource-intensive home care services are needed to successfully address ALC patients' care needs in the community. A substantial portion of ALC patients waiting for LTC placement in acute and complex care hospitals may be more appropriately cared for in community settings if adequate community-centred resources are put in place.

The Design of a Case Management System for ALC Patients

Summary The design of a database management system is described as an attempt by an urban teaching hospital to improve the quality of care and contain costs of Alternate Level of Care (ALC) patients. Preliminary research findings indicate that particular discharge problems, discharge plans, and demographic characteristics of patients are related to prolonged ALC lengths of stays. These findings have helped staff to identify patients most at risk resulting in improved discharge planning.

An alternate level of care, the prospective payment system and the challenge of extended care

Due to demographic, morbidity and public policy shifts, the health care system is undergoing a profound change. In this unsettled context the problem of the alternate level of care (ALC), or sub-acute care, patient has acquired a new meaning and importance. An ALC patient falls between the traditional levels of acute and skilled care. This study tries to identify the nature and scope of the ALC problem in Illinois, because it is symptomatic of changing morbidity patterns; because it exemplifies the consequent dilemmas for the health care industry; and because it typifies the ambivalent response of the health care institutions. The data reveals that the ALC patients are backed up in 78% of the hospitals in the state, and they pose a heavy burden and future risk both to hospitals and nursing homes. The hospital industry has sensed the challenge of extended care, but it is not responding with a reasoned and concerted strategy. Rather, in a worsening competitive situation, a unique opportunity to bridge the hiatus between acute and long-term care, and to build towards a humane and equitable system of care, may pass us by.

Alternate level of care patients in public general hospital psychiatry

Little has been written on the relationship between psychiatric services in public general hospitals and in other institutional settings. The authors analyze the interaction between them and its effects on quality of care. They suggest that clinicians and administrators are biased in favor of institutional care. Several recommendations for further research on the subject are made.