Ontario’s ALC problem…and you.
What is ALC?
Short answer: Alternate Level of Care
(Note: This post will only be discussing ALC as it applies to beds
in acute care hospitals.)
Ontario’s Ministry of Health and Long-Term Care (MOHLTC)
defines ALC as, “When a patient is occupying a bed in a hospital and does not
require the intensity of resources/services provided in this care setting…”
To paraphrase, a patient designated as ALC has recovered to
a level where they no longer require the
services of the acute care hospital, but
occupy an acute care hospital bed due to the lack of available services
and supports in the community or home; or lack of available beds in a nursing home,
long-term care facility, rehabilitation hospital, or other assisted-living
facility.
How many ALC patients are there in Ontario?
As per the Ontario Hospital Association (OHA):
-
On September 30, 2014, there were 2,547 patients designated ALC
waiting in an acute care bed in Ontario.
-
In August 2014, ALC-designated patients were occupying 14.7%
of acute care inpatient beds in Ontario.
(That is almost 1 in 6 acute care beds!)
Why is this a problem?
1) Hospital beds taken up by ALC patients cannot
be used for new patients requiring admission to hospital, meaning they wait on
a stretcher in the Emergency Department (ED) – sometimes for days.
-
The beds taken up by admitted patients in the ED cannot be used to see
new Emergency Department patients – resulting in longer waits to get into the
ED to be assessed by a physician and receive the treatment you need.
2) Hospital beds taken up by ALC patients cannot
be used for new patients requiring admission to hospital after surgery – so surgeries
are often cancelled or delayed.
-
Most times patients will find out that their surgery is cancelled on the
day it was to happen.
What can be done about the ALC problem?
1) In the short-term, with lack of resources in
the community and no nursing home beds, long-term care beds, etc. to send
patients to, hospitals are left with little options.
-
One option is to apply for “Category 1A Crisis” status for their ALC
patients - if the beds taken up by ALC
patients are preventing acute care admissions, causing cancellation of surgical
cases, preventing admissions to critical care beds, or the number of “no-bed”
admitted patients in the ED is affecting the operation of the ED.
There are a couple of issues with
this:
-
Some hospitals are in “gridlock” situations, with all of the above affecting
them so often, and on an ongoing basis that after a while the effect of frequently declaring
“Category 1A Crisis” status would make little difference if there is still not
a way to decant this pressure off the hospital.
-
The provincial agency responsible for arranging ALC services and
placements (the regional Community Care Access Centres - CCAC) can go through
the lengthy process of arranging appropriate placement for ALC patients – and then
the patient (or their Substitution Decision Maker – SDM) can refuse the bed
arranged for them for any (or no) reason, and continue to take up an acute care
bed. We have many patients that have
been ALC in acute care hospitals across the province for over 2 years for this
reason.
(- Hospitals
should charge patients for the full costs associated
with their stay if they refuse to be discharged.) (They should consider doing this at the acute-care rate
– as they would be preventing an acute-care patient from occupying that bed.)
2) Address the problem!
a) The Ontario Government
under the leadership of Liberal Dalton McGuinty “unfunded” (aka closed)
numerous beds in almost every hospital across the province to pay for other
Ministry of Health projects at the time that needed funding – i.e. renovating
existing hospitals, new hospital buildings, and the creating of the regional
Local Health Integrated Networks (LHINs) (aka another level of government bureaucracy),
etc.
- Hospitals cannot admit patients
to these unfunded beds without incurring the cost themselves – as they will not
be reimbursed by the government, or only receive partial reimbursement.
b) During that same period,
the government closed nursing homes and long-term care facilities whose
buildings required costly upkeep due to their age before having new facilities
built to absorb these patients.
-
The government promised new facilities, but these never materialized in
many regions.
-
Ultimately some acute care beds in hospitals had to be re-designated as “complex
continuing care” due to the lack of appropriate beds in the community.
- This re-designation of beds at one hospital
then places further pressure on surrounding hospitals.
c) CCAC needs to adequately fund
home and community supports to get patients out of hospitals.
-
CCAC has strict limits on the amount of support that can be provided to
any single patient.
- There have been numerous similar cases where
a patient remains in hospital simply because CCAC will not provide funding for
24/7 personal support workers (PSWs) for that patient.
- As a result, these patients not only have to
remain in hospital, but often have to be kept in “step-down” units where the
nurse to patient ratio can be 1-to-1, or 1-to-2.
- Maintaining this staffing ratio is quite
expensive, but if the hospital does not (or cannot) designate the patient as
ALC, there is no motivation for CCAC to provide the additional level of care at
home – as the CCAC and the LHIN are not as directly accountable for how the
hospital spends their money on admitted, non-ALC patients.
Links:
Ontario Hospital Association (OHA) - information on ALC and
ER wait times - http://www.oha.com/CurrentIssues/Issues/eralc/Pages/eralc.aspx
and
http://www.oha.com/CurrentIssues/Issues/Documents/OHA%20ALC%20September%202014.pdf
Ontario Ministry of Health and Long-Term Care (MOHLTC) - ALC
definition - http://www.health.gov.on.ca/en/pro/programs/waittimes/edrs/alc_definition.aspx
MOHLTC/CCAC – information on “Category 1A Crisis” status - http://www.health.gov.on.ca/english/providers/pub/manuals/ccac/cspm_sec_12/12-3.html
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