Alternative Level of Care (ALC) in Ontario

As with many health care issues, the ALC “problem” can be reviewed using the “Right Brothers” method – the right care, at the right time, in the right place, and by the right provider.

Right Care

Most ALC patients are the frail elderly, a group requiring specific interventions that differ from usual adult care.  The use of best practice guidelines* and/or pathways* assists health professionals in developing an appropriate and individualized care plan.  The “right care” could mean maintenance of current status or improvement in some aspects, e.g., improved self-care or ambulation. 

Right Time

Timely ALC designation has often been a contentious issue. Some physicians want to spare their patient the required payments and refuse to make the designation.  Others make the designation too early in order to enhance their length of stay statistics, or to get the patient moved from their service.   A sensible rule of thumb: If the patient could go to their final destination e.g., nursing home today, they can be designated ALC. Timeliness can be audited* to ensure compliance, and education sessions* instituted as needed.

Right Place

There are two facets to the “place” issue. The first is the final destination for the patient, e.g., nursing home, rehabilitation, or chronic care. It is useful to monitor* the initial proposed destination and the actual discharge setting.  This data helps health professionals make informed decisions with the patient/family, supports hospital administrative decisions, and provides the MOHLTC with accurate statistics for planning needed services.

The second “place” issue is whether ALC patients should be centralized in one unit, or remain on the regular wards. Studies have shown that centralization of like groups of patients improves outcomes due to consistent and knowledgeable care.

However, this decision* depends on the number of ALC patients usually in the hospital, the average length of ALC days, and sometimes on the care requirements of the specific patient, e.g., peritoneal dialysis.

Right Provider

A Registered Practical Nurse could assume total care for the stable ALC patient, either on the regular ward or in a special unit.  The use of unregulated health care providers, e.g., health care aides, in hospital situations is not usual practice in Ontario.  The addition of other providers such as physiotherapy, occupational therapy, or dietitians, etc., should also be part of the care plan as needed.  A Geriatric Nurse Specialist or a Registered Nurse with geriatric education and interest could assist in care planning and/or interventions for specific issues, e.g., bladder training.

Physician coverage can be a problem if the patient was admitted under a surgeon or other specialist and has no Family Practitioner (FP). Since Geriatricians are in short supply, perhaps a FP or Hospitalist with a special interest in geriatrics could provide primary care.              

* For further information and/or assistance with these items please contact us.