Strategies to Reduce Alternate Level of Care

Key Messages

What Is the Issue?

• Alternate level of care (ALC) is when a patient is occupying a bed in a hospital and does not require the intensity of resources or services provided in that hospital. ALC is a persistent barrier to providing efficient health care in Canada, as it is in most health systems worldwide (where ALC is referred to as delayed discharge).
• Older adults (aged 65 years or older) who require placement in residential care are the largest subgroup of the ALC patient population.
• Analyzing ALC use data can inform decision-makers about data trends and which jurisdictions have reduced ALC times.
• By understanding the strategies, policies, or other interventions that have been used to reduce ALC in Canada, and which have been successful at minimizing ALC, decision-makers can consider which strategies to implement in their health jurisdictions.

What Did We Do?

• We analyzed Canadian Institute for Health Information data related to ALC and average length of ALC in older adults in the provinces and territories of Canada.
• We conducted an environmental scan of the academic and grey literature to:
  • identify strategies to address ALC in older adults in Canada
  • identify strategies that have been effective in reducing ALC in older adults in Canada.

What Did We Find?

• In 2022 to 2023, Canada (excluding Quebec) had 15 ALC hospitalizations per 1,000 population, 369 total ALC days per 1,000 population, and a mean of 25 ALC days per hospitalization in patients aged 65 and older awaiting admission to residential care or elsewhere.
• While there were variations across jurisdictions, the trends in ALC over time for adults aged 55 years and older were relatively consistent.
• Patients with more ALC days were aged 75 years and older, had lower incomes, and were admitted to the hospital as urgent.
• We identified 19 strategies that addressed ALC in older adults in Canada. These included input, throughput, and system-level interventions, which we categorized as live information sharing, recommended initiatives, tools and guidelines, practice changes, and infrastructure and finance.
• We identified 4 studies that reported a favourable effect of a throughput or system-level strategy compared to no strategy or standard care on ALC hospitalizations, length of stay, or discharge to home.
  • Two throughput strategies may be effective:
    • The Subacute Care for the Frail Elderly (SAFE) Unit improved ALC length of stay (LOS), hospital LOS, and discharge to home.
    • The Transitional Care Unit improved discharge to home.
  • Two system-level strategies may be effective:
    • Home First improved ALC hospitalizations, ALC LOS, and discharge to home.
    • Behavioural Supports Ontario improved ALC hospitalizations and ALC LOS.

What Does This Mean?

• We found common themes in our environmental scan that decision-makers may incorporate into strategies for addressing ALC in older adults waiting for residential care, including the provision of integrated care, promotion of age-friendly care, early identification of patients at risk of ALC, sharing of tools and resources, transitional care, and inclusion of families and caregivers in care planning.
• This report may serve as the first step for future systematic reviews or other evidence syntheses with a broader scope. Future research might investigate the factors that contribute to ALC and interventions to address those factors.