Alternate level of care (ALC) throughput ratio

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Alternate level of care (ALC) refers to a patient who is occupying a bed in hospital and waiting to receive care elsewhere. A designation of ALC can have negative effects on the patient (for example, through risk of hospital-acquired infections and functional decline while in hospital), family, and the health care system (for example, through decreased access to acute-care hospital services for patients who truly require them). The ALC throughput ratio reflects the rate at which patients are being discharged versus designated ALC.  It is important to understand the causes of delayed transitions and discharge for individuals designated as ALC, and work with other partners within the health care system to ensure that improvements support access to care in the right place at the right time.

In 2023/24, hospitals took an important next step toward better understanding the root causes of delayed transitions in care through completion of the ALC Leading Practices Self-Assessment. This work has helped to identify the current state and has supported organizations to establish a baseline for improvement from which they can plan and implement relevant change concepts and ideas.

Key Resources

Change Ideas

Use data to understand the population most at risk for ALC designation and the care that they requir

Access Wait Time Information System (WTIS) data, monthly reports, etc.
Conduct asset mapping to understand the current- state capacity of services available for the population most at risk

Include patients and caregivers as part of the care team

Develop care plans and goals of care collaboratively with patients and caregivers.
Implement an approach to measuring patient and caregiver experience and outcomes.

Optimize processes for early identification, assessment, and care plan development prior to ALC designation

Use a screening process or tool to identify patients at risk of delayed transitions in care
Identify and document patients’ baseline functional status
Complete comprehensive assessment that addresses physical, cognitive, functional, and psychosocial domains
Determine patients’ functional goals and restorative potential to inform the care plan
Develop care plans to address identified care needs with a focus on transition to the community first.
Implement evidence-based rehabilitative care pathways
ALC Leading Practices Guide
RCA & PGLO Framework for Rehabilitative Care for Older Adults Living with or at Risk of Frailty
RCA Post-Fall Pathway: Emergency Department
RCA Direct Access Priority Process

Deliver senior-friendly care interventions throughout admission

Deliver a minimum standard of daily care (7 days per week) to all patients regardless of ALC designation or discharge destination
Minimize risk of longer-than-expected lengths of stay by embedding evidence-based practices that actively mitigate the risk of avoidable deconditioning, falls, delirium, etc.
Provide quality care and support to patients with, or at risk of responsive behaviours or personal expressions
Senior Friendly Care implementation resources for delirium prevention
Senior Friendly Care implementation resources for mobilization
Behavioural Supports Ontario

Ensure consistent application of the ALC definition

Ensure accurate application of an ALC designation that considers patients’ restorative potential within the current accurate or post-acute care setting
Provide training to ensure clarity about when to recommend an ALC designation
CIHI Job Aid: Guidelines to support ALC designation by clinicians

Transition patients requiring palliative support back to the community

Use evidence-based tools to identify individuals who would benefit from palliative care
TheOntario Palliative Care Network’s Tools to Support Earlier Identification for Palliative Care outlines recommended tools that can be integrated into various settings of care
Implement an evidence-based model of care for providing palliative care in community settings
TheOntario Palliative Care Network’s Palliative Care Health Services Delivery Framework outlines recommendations to guide organization and delivery of palliative care and includes a patient pathway
Foster collaboration and communication internally and across care settings to support discharge to home or to other dedicated end-of-life settings
Explore virtual platforms for connecting with specialists or with patients, especially in remote areas (e.g., Ontario Telemedicine Network’s eConsult, eVisits, and Virtual Palliative Care programs)
Reach out to your Regional Palliative Care Network to get information on supports and partners in your local area
Share resources (staff, technology, or training opportunities) among partners in your region (e.g., sharing and co-funding a nurse practitioner among partners within a region, or holding regional educational events)

Transition patients requiring support to age in place back to the community

Use evidence-based tools to identify individuals living with or at risk of frailty
Provincial Geriatrics Leadership Ontario and the Ontario Collaborative for Aging Well have identified recommended frailty screening tools that can be integrated into various settings of care