Alternate Level Of Care Research Articles

Patient Engagement as a Component of a Learning Healthcare System: A case study using small area rate variation research in Nova Scotia, Canada

ABSTRACTObjectivesThe objective was to develop a framework for incorporating patient engagement into administrative health database research. In an examination of variation in high-cost health service use using administrative data, patient experience was incorporated as an additional source of knowledge to inform evidence-informed policy making in a learning healthcare system framework.MethodThe study described variation in the rate of high-cost use by area within Nova Scotia, Canada, and isolated local factors contributing to the rate of high-cost use to inform targeted intervention development. Regression analysis was used to determine where the rate of high-cost use was driven by known contributors, such as demographics or disease patterns. Peer-leaders from provincial chronic disease management programs (Patient Navigators) were recruited as study team members. They were invited to help describe their collective experience of patient-based factors that may contribute to high-cost use, including access to care and multi-morbidity in their regions.ResultsThe outcome of this ‘proxy’ patient engagement was measured by the extent to which the input from the Patient Navigators influenced study protocol, interpretation of results and communication of findings. The patient voice helped describe the extent of variation, contextualize the findings, and suggested additional contributory factors not revealed by the analysis of administrative health data. For example, the Patient Navigators described regional discrepancies in available services for managing chronic disease and variation in the approach to discharge planning. In this way, the patient experience was incorporated to attempt to explain rates of high-cost use in areas that could not be explained by known contributors. Further, patient experience with travel distance to receive care and alternate levels of care helped to generate questions for future research.ConclusionPatient experience is an invaluable input into health research that contributes to health system planning. This research incorporated ‘proxy’ patient experience to produce evidence to inform targeted interventions aimed at reducing the rate of high cost-users. The identified areas where focused interventions or reforms could yield material benefits for efficient delivery of health care.

Clinical characteristics and preventable acute care spending among a high cost inpatient population.

BackgroundA small proportion of patients account for the majority of health care spending. The objectives of this study were to explore the clinical characteristics, patterns of health care use, and the proportion of acute care spending deemed potentially preventable among high cost inpatients within a Canadian acute-care hospital.MethodsWe identified all individuals within the Ottawa Hospital with one or more inpatient hospitalization between April 1, 2010 and March 31, 2011. Clinical characteristics and frequency of hospital encounters were captured in the information systems of the Ottawa Hospital Data Warehouse. Direct inpatient costs for each encounter were summed using case costing information and those in the upper first and fifth percentiles of the cumulative direct cost distribution were defined as extremely high cost and high cost respectively. We quantified preventable acute care spending as hospitalizations for ambulatory care sensitive conditions (ACSC) and spending attributable to difficulty discharging patients as measured by alternate level of care (ALC) status.ResultsDuring the study period, 36,892 patients had 44,066 hospitalizations. High cost patients (n = 1,844) accounted for 38 % of total inpatient spending ($122 million) and were older, more likely to be male, and had higher levels of co-morbidity compared to non-high cost patients. In over half of the high cost cohort (54 %), costs were accumulated from a single hospitalization. The majority of costs were related to nursing care and intensive care unit spending. High cost patients were more likely to have an encounter deemed to be ambulatory care sensitive compared to non-high cost inpatients (6.0 versus 2.8 %, p < 0.001). A greater proportion of inpatient spending was attributable to ALC days for high cost versus non-high cost patients (9.1 versus 4.9 %, p < 0.001).ConclusionsWithin a population of high cost inpatients, the majority of costs are attributed to a single, non-preventable, acute care episode. However, there are likely opportunities to improve hospital efficiency by focusing on different approaches to community based care directed towards specific populations.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-016-1418-2) contains supplementary material, which is available to authorized users.

Abstract TP417: Improving Stroke Rehabilitation Intensity Data Collection: Collaborative Implementation of a Quality Assurance Framework

Background and Issues: A minimum of 3 hours of rehabilitation intensity (RI) is a stroke best practice standard of care that has been established in Ontario. As collection of RI time has been mandated in Ontario, the Ontario Stroke Network has been working with stakeholders to capture RI data using workload measurement systems (WMS). Given that this is a new indicator and variability exists in use of WMS across Toronto, there is a need for standardization in RI data collection. Purpose: To develop a quality assurance (QA) framework for RI data collection in Toronto that can be used locally and provincially to ensure consistent and accurate data collection and reporting. Methods: The Toronto Stroke Networks formed a working group comprised of clinical and decision support leads from 6 rehabilitation centres. This group developed standard approaches to capturing RI data. They also examined factors that influence the quality of the data, ranked these factors by level of influence on data quality, and established mitigation strategies for the top ranked factors. Additionally, a reporting and monitoring plan was determined. Results: Through collaborative sharing of information, a QA framework was developed and adopted by the group. The top ranked factors affecting data quality included: 1) When the RI data field is left blank; 2) Inaccurate data entry by staff; 3) Variations in service interruptions and alternate level of care; and 4) Timeliness in entering data. Mitigation strategies included use of lock out periods, clear definitions, processes for staff feedback and education, and establishment of a quarterly reporting structure for organizational comparison. This QA framework has been shared with provincial stakeholders to inform system planning in other regions. Conclusions: As data accuracy in capturing RI data is important for current state analysis and benchmarking, a comprehensive QA framework was developed to support data accuracy and has been used for local monitoring and reporting of RI data. Identified factors that influence data quality related to processes for data capture. As mitigation strategies will further support these processes, this QA framework ensures accurate data collection and confidence in using RI data to support system planning.

The Untold Story of Being Designated an Alternate Level of Care Patient

Much of the research and policy reports on Alternate Level of Care (ALC) in Canada have focused on the impact ALC has on acute care services. To date, the experiences and opinions of those who must wait in hospital for alternate services have been largely absent from discussions.A qualitative study was conducted with patients and families designated as ALC in one urban and two rural hospitals in Atlantic Canada. Data were analyzed using content analysis.Three themes emerged from the data: a perception of normalcy, being old but not sick and anticipating relocation to another facility.ALC is an important issue for patients and their families. Policy directives aimed at addressing the causes and impacts of ALC, identification and provision of appropriate supportive care in the community and sensitivity to the impact of ALC for individuals designated as ALC are needed.

From Global to Local: Inequalities in Health and Healthcare

This is the year that time runs out on the Millennium Development Goals (MDGs). Established following a United Nations summit in 2000, countries around the world committed to eight goals – including halving extreme poverty, stopping the spread of HIV/AIDS and reducing child mortality (United Nations 2015). While some questioned the process for establishing and monitoring the goals, the MDGs have galvanized and focused efforts from governments, civil society and other partners over the past 15 years. There have been some remarkable achievements during this period. Globally, the number of people living in extreme poverty is down by more than half since 1990, the year against which MDG targets were benchmarked. So is under-five mortality, which dropped from an estimated 90 to 43 deaths per 1,000 live births. And maternal mortality and new HIV infections have fallen by 45 and 40 per cent, respectively. There were similar reductions in the prevalence of tuberculosis and mortality from the disease. That said, progress towards the 21 MDG targets is uneven and not all milestones set for 2015 will be achieved. Large gaps exist between countries and within them. For example, children under five in the poorest households in developing regions are almost twice as likely to die as those in the richest, although this gap seems to be narrowing in at least some countries. However, the United Nations notes that progress in some other areas – such as measles vacci-nation – has stalled since 2010. Their report highlights the fact that many of the 21.6 million infants who did not receive the measles vaccine in 2013 were “from the poorest and most marginalized communities, residing in especially hard-to-reach areas” (United Nations 2015). Similar patterns of health and disease are seen around the world; Canada is no exception. For instance, there is a 10-year gap in life expectancy at birth among provinces and territories (Statistics Canada 2013). Rates of arthritis, diabetes, hypertension, injuries and other diseases also differ among jurisdictions. Zooming in to the health region level, variations are even wider (Greenberg and Normandin 2011; Statistics Canada 2015). This “postcode lottery” represents the sobering reality that driving a few hours makes the difference between health status that is among the best in the world and one that reflects average life chances from half a century or more ago. In this issue of the journal, Sara Allin, Jeremy Veillard, Li Wang and Michel Grignon study regional variations to understand how we can improve the efficiency with which the health system translates its resources into improved outcomes. There are no simple answers – but neither is this a simple problem. Their research highlights a combination of population, behavioural and managerial factors that help to explain variations in efficiency. Other papers bring new perspectives to bear on equally challenging questions. The most personal explores the views of individuals designated as alternative level of care in Atlantic Canada and those of their families. Other authors examine system-level issues that have personal consequences for those they affect, such as generic drug pricing, the reimbursement of medications for rare diseases and the choice/implications of services from different types of maternity care providers. Whatever areas of health policy you focus on, I hope that you will find food for thought, for study and for action in the journal's pages.

Frailty indices as a predictor of postoperative outcomes: a systematic review protocol

Frailty indices as a predictor of postoperative outcomes: a systematic review protocol

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.

Patterns of health care use in a high-cost inpatient population in Ottawa, Ontario: a retrospective observational study.

A small proportion of patients account for the majority of health care spending. We used detailed clinical and administrative data to explore clinical characteristics, patterns of health care use and changes in cost profiles over time among high-cost inpatients in an acute tertiary care hospital in Ottawa, Ontario. We identified all people who had 1 or more inpatient admissions to The Ottawa Hospital between Apr. 1, 2009, and Mar. 31, 2012. We calculated the direct inpatient costs using case-costing information to categorize patients into persistently high-cost, episodic high-cost and non-high-cost groups. Within each group, we used discharge abstracts to measure encounter-level characteristics and patterns of inpatient health care use over time. We also developed transition matrices to explore how inpatient costing states changed over time. During the study period, 100178patients had 132996hospital admissions. Hospital spending was often limited to a single year for most of the patients (90.2%), with only a small proportion (7.4%) of patients remaining in the high-cost group in the subsequent year. Patients in the persistently (n = 236) and episodic (n = 5062) high-cost groups were often older, had medically complex conditions and generated most of the costs from nursing care and intensive care. Compared with patients in the other cost groups, those in the persistently high-cost group were more likely to have multiple readmissions (43.4%) and multiple placements in an alternate level of care (19.0%) and were high users of health care services outside of the hospital setting. Hospital spending was often limited to a single year for most patients, and only a small proportion of patients remained in the high-cost group in the subsequent year. These persistently high-cost patients had medically complex conditions and often required expensive care. A greater understanding of the circumstances that result in persistent hospital spending remains an area for future work, including an exploration of the potential barriers impeding efficient transition out of acute care for high-risk patients.

Patient Needs, Required Level of Care, and Reasons Delaying Hospital Discharge for Nonacute Patients Occupying Acute Hospital Beds

Abstract: This study aims to determine the proportion of nonacute patients occupying acute care beds and to describe their needs, the appropriate level of alternative care, and reasons preventing discharge. Data from 952 patients hospitalized in an acute care unit for 30 days were obtained from their medical charts and by consulting with the medical team at two tertiary teaching hospitals. Among them, 333 (35%) were determined nonacute on day 30 of hospitalization. According to the Appropriateness Evaluation Protocol (AEP), 55% had no medical, nursing, or patient needs. Among nonacute patients with AEP needs, 88% were related to nursing/life‐support services and 12% related to patient condition factors. Regarding alternative level of care, 186 (56%) were waiting for out‐of‐hospital resources, of which 36% were waiting for palliative care, 33% for long‐term care, 18% for rehabilitation, and 12% for home care. For the remaining 147 (44%) nonacute patients, the alternative resources remained undetermined although acute care was no longer required. Main reasons preventing discharge included unavailability of alternative resources, ongoing assessment to determine appropriate resources, ongoing process with community care, and family/patient education/counseling. Available subacute facilities and community‐based care would liberate acute care beds and facilitate their appropriate use.

Head and neck issues in older adults.

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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.

Predictors of in-hospital mortality and complications in very elderly patients undergoing emergency surgery.

IntroductionWith the increasing aging population demographics and life expectancies the number of very elderly patients (age ≥ 80) undergoing emergency surgery is expected to rise. This investigation examines the outcomes in very elderly patients undergoing emergency general surgery, including predictors of in-hospital mortality and morbidity.MethodsA retrospective study of patients aged 80 and above undergoing emergency surgery between 2008 and 2010 at a tertiary care facility in Canada was conducted. Demographics, comorbidities, surgical indications, and perioperative risk assessment data were collected. Outcomes included length of hospitalization, discharge destination, and in-hospital mortality and morbidity. Multivariable logistic regression was used to identify predictors of in-hospital mortality and complications.ResultsOf the 170 patient admissions, the mean age was 84 years and the in-hospital mortality rate was 14.7%. Comorbidities were present in 91% of this older patient population. Over 60% of the patients required further services or alternate level of care on discharge. American Society of Anesthesiologist Physical Status (ASA) Classification (OR 5.30, 95% CI 1.774-15.817, p = 0.003) and the development of an in-hospital complications (OR 2.51, 95% CI 1.210-5.187, p = 0.013) were independent predictors of postoperative mortality. Chronological age or number of comorbidities was not predictive of surgical outcome.ConclusionsMortality, complication rates and post-discharge care requirements were high in very elderly patients undergoing emergency general surgery. Advanced age and medical comorbidities alone should not be the limiting factors for surgical referral or treatment. This study illustrates the importance of preventing an in-hospital complication in this very vulnerable population. ASA class is a robust tool which is predictive of mortality in the very elderly population and can be used to guide patient and family counseling in the emergency setting.

Analysis of the Influencing Factors Associated With Being Designated Alternate Level of Care

A health care organization within the Western region of Newfoundland and Labrador has been experiencing high levels of alternate level of care (ALC) cases and days within their acute care units. The majority of these individuals are older adults. The overall goal of this mixed-methods study was to identify factors for becoming designated ALC and to present recommendations for early intervention. This research found that older female adults with co-morbid conditions who access emergency medical services often are admitted to a hospital. The authors also found that once these patients are admitted to an acute care unit, they tend to experience functional decline that may also result in being designated ALC. This study outlines recommendations that may prevent patients from being designated ALC.

Clustering clinical departments for wards to achieve a prespecified blocking probability

When the number of available beds in a hospital is limited, it can be beneficial to cluster several clinical departments such that the probability of not being able to admit a patient is acceptably small. However, not all clinical departments can be clustered for cross-infection reasons. In addition, patients from one clinical department should not be spread out over the entire hospital as this complicates the process of doing rounds and may result in alternate level of care. In this paper, we consider a situation where wards with a fixed number of beds are given. The question is how to cluster the clinical departments and to determine the assignment of these clustered departments to the available wards such that the assigned beds are sufficient to guarantee a blocking probability below a prespecified percentage. We first give an exact formulation of the problem to be able to achieve optimal solutions. However, computational experiments show that the resulting computation times for this model are too long for it to be applicable in practice. To reduce the computation time, we introduce two heuristic solution approaches. The first heuristic uses the same formulation as the exact model, however, the number of required beds is approximated by a linear function. The resulting model is again solved by an exact solver. The second heuristic uses a restricted version of the exact model within a local search approach. Hereby, the local search is used to determine the assignment of clinical departments to clusters and the exact model is used to determine the assignment of clusters to wards.

Uncertainty and Alternate Level of Care: A Narrative Study of the Older Patient and Family Caregiver Experience

Older adults in Canada who have multiple illnesses and are awaiting placement in long-term care are greatly impacted by alternate level of care (ALC). The purpose of this narrative study was to record the experiences of hospitalized older adults and their family caregivers after the patient is designated as requiring ALC. The researchers conducted 21 interviews with 5 older patients and 4 of their family caregivers. The interviews were transformed into stories summarizing the participants' experiences and analyzed for common themes. An overall finding was that uncertainty is integral to the experience of ALC as expressed under 3 themes: I never thought I'd end up like this, I don't know, and waiting. To improve the ALC experience, comprehensive strategies should be developed at the individual, organizational, and structural level to better manage uncertainty while seeking to reduce the occurrence of ALC among older patients.

Examining Waiting Placement in Hospital: Utilization and the Lived Experience

This mixed-methods study addressed the problem that although waiting placement is considered a major hospital utilization issue, minimal evidence exists to highlight the extent of it and the personal impact of waiting placement. An analysis of two years of complete hospital data for the Canadian province of Alberta was undertaken to examine waiting placement rates and describe waiting placement patients. Qualitative interviews and observations of elderly patients waiting in hospital for nursing home placement were also undertaken to gain an understanding of the lived experience of waiting for placement in hospital. Only 1.8% of all inpatients were waiting placement with an ALC (Alternative Level of Care) designation, 80% of ALC waits were less than 41 days (mean=29.85, median=14), and 2.2% of total hospital bed days in these two years were used by ALC patients. Three qualitative themes emerged: (a) coming to a realization of this significant move, (b) waiting is boring and distressing, and (c) hospitals are not designed for waiting placement. The findings of this study should raise awareness that although relatively few people wait placement in hospital, there are some major possible negative effects of waiting for placement in hospital for those who wait; with remedies to address waiting placement care deficits needed.

Alternative Level of Care: Canada's Hospital Beds, the Evidence and Options

Patients designated as alternative level of care (ALC) are an ongoing concern for healthcare policy makers across Canada. These patients occupy valuable hospital beds and limit access to acute care services. The objective of this paper is to present policy alternatives to address underlying factors associated with ALC bed use. Three alternatives, and their respective limitations and structural challenges, are discussed. Potential solutions may require a mix of policy options proposed here. Inadequate policy jeopardizes new acute care activity-based funding schemes in British Columbia and Ontario. Failure to address this issue could exacerbate pressures on the existing bottlenecks in the community care system in these and other provinces.

Path Dependence and Health Policy: Intersections between the Past and the Future

On walmgate street in york, england, you can order kebabs or burgers from a restaurant with a storefront that is exactly one perch long, a property boundary and unit of measurement that survives from Viking times.1 Its persistence hundreds of years and many generations later in the modern streetscape is a classic example of path dependence. While path dependence is perhaps most obvious in the case of physical structures, they are by no means the only context in which current decisions or situations are shaped by past circumstances. Examples in economic, cultural and other contexts abound. Indeed, one could argue that embedding effective practice and healthy behaviours – or uprooting well-established practices that no longer serve us well – is one of the key challenges of health management and policy. At the core is the fundamental question: how can we make the right thing to do the easy thing to do? This applies to thousands of micro-level decisions made every day, such as how best to organize a surgical cart, and to broad challenges in health promotion, such as which features of urban design are most likely to encourage physical activity at the population level. This issue of Healthcare Policy / Politiques de Sante features a number of papers that address aspects of this challenge, from documenting gaps and their causes to exploring policy options to address them. Brian Hutchison focuses on primary healthcare reform. This is an area of enduring policy focus around the world, reflecting its complexity and importance to health and healthcare systems. Hutchison's paper takes a fresh look at what has changed, what has not and why. In contrast, Sisira Sarma and his colleagues examine a very specific aspect of family practice: whether use of health information technology in primary care is associated with patient visit numbers and visit length. Pharmaceutical policy is another highly complex area where history and context affect decisions and outcomes today. This issue of the journal explores a number of facets of this domain, from cost-control mechanisms in private or public drug plans (Jillian Kratzer et al.) to potential conflict of interest in reimbursement decisions (David Hughes and Bryn Williams-Jones). The policy choices that we make in these and other areas are likely to influence costs and outcomes for years to come. Likewise, Jason Sutherland and Trafford Crump address the mismatch between patient needs and resources used represented by alternative level of care in hospitals. Future decisions about the policy alternatives that they discuss may well be informed by the analysis of Saad Rais and colleagues on high-cost users of healthcare services. Many of the home care clients studied by Diane Doran and her co-authors from across the country would fall into this category. Their research provides important insight into the frequency and types of adverse events experienced for those receiving home care. Whichever areas of health policy are your current focus, I hope that you will find new insights and food for thought in the journal's pages. After all, to twist George Santayana's famous quotation somewhat, those who are unaware of how the past influences the present are condemned to repeat it – and to reinforce gaps in quality, access and health that exist today or, alternatively, risk inadvertently disrupting those paths that help us to achieve better health, better care and better value.

Seniors and Alternative Level of Care: Building on Our Knowledge

There is ongoing concern that acute care beds in Canada are occupied by seniors who are waiting to be discharged to a more appropriate level of care. These individuals, who no longer require acute care services, are commonly designated as alternative level of care (ALC) patients. In this study, the authors examined the characteristics of patients transitioning from acute care to home care or residential care.

Long Stay Hospital Patients in Acute Care Hospital beds - What does Dementia have to do with this?

The Canadian Institute of Health Information (CIHI) has established a patient classification called Alternative Level of Care (ALC) that applies to patients who have completed the acute care phase of their treatment but remain in an acute care bed (1). It is estimated that 5-14% of all acute care beds in Canada are occupied by ALC patients (2). In Atlantic Canada specifically, an equivalent of 468 acute care beds were occupied by ALC patients in 2009-2010 (3). ALC patients tend to be older and the majority have a diagnosis of dementia.