For a small rural hospital with 19 beds like South Huron, even one patient designated as Alternate Level of Care (ALC) has a large impact on the hospital’s ability to provide acute, rehab, and complex care to patients.
The ALC issue is a symptom of a system-wide problem, where patients who no longer require hospital care are unable to transition to a more appropriate setting due to capacity issues, complex health and social needs, and various other reasons.
South Huron Hospital has been successful in significantly reducing their ALC rate per 100 patient days from a high of 29.2 to as low as 5.6 over a quarter.
Health Quality Ontario had a chance to catch up with the team at South Huron to learn more about how they achieved their ALC success. The team included:
- Gina Taylor, former Interim Chief Nursing Executive
- Jessie Brown, Social Worker
- Heather Klopp, Director of Ambulatory Services, SHHA, and Director of Health Support Services at Grand Bend Area Community Health Centre
- Tammy Dickins, Health Records Coder, member of QIP team and involved in Health Information Management
Gina Taylor, Former Interim Chief Nursing Executive, Brittany Beauchamp, Pharmacy Technician, Kelly Campbell, Ward Clerk, Teresa Doupe, RPN, Tiffanie Poortinga, RN, Dr. Neeraj Patel, Lead Hospitalist
Can you describe the strategies you used to significantly improve your ALC rates?
There were a number of strategies we used to make an impact on our ALC rates.
Starting discharge planning early
One of the most important changes we’ve made is to begin discharge planning as soon as possible instead of waiting until a patient is designated ALC. We have interdisciplinary meetings with South West LHIN Home and Community Care, social work, the hospitalist and our Chief Nursing Executive to create appropriate discharge plans for patients.
To further focus our efforts, we have changed the name of our “family meetings” to “discharge planning meetings.” It’s a small change, but makes a big impact on how we work with patients.
Offering appropriate discharge options to patients
In our local area, there are limited options for Long-Term Care beds, and until recently, no local hospice. Access to affordable retirement housing and supportive housing remains a challenge in our region.
With this in mind, nursing staff, physicians, social work, and physiotherapy conduct regular ALC reviews to establish action plans with South West LHIN Home and Community Care to address barriers to discharge and facilitate additional options for discharge or transfer.
For example, for patients who do not have complex needs, the new centralized Community Support Service (CSS) Network available through the South West LHIN works very well to set patients up with supports they’ll need in the community. Through CSS, health service providers and their patients are able to easily access supports with one call.
Even when patients receive services from multiple CSS providers such as Meals On Wheels, VON, and One Care, their care is coordinated so that they experience CSS as a single sector rather than isolated agencies.
For complex patients, we use the Health Links Approach to Care. The South West LHIN Home and Community Care Coordinator is a nurse who is located at South Huron Medical Centre which is owned and operated by SHHA and is situated across the street from the hospital. With this co-location, it is easy to get together to have Health Links coordinated care meetings.
What we struggle with is consistently and reliably being able to mobilize a Home First program given challenges with Personal Support Worker availability in our area and nuances in working across two neighbouring LHINs.
Discharge mapping
We use a whiteboard in our hospital’s nursing station to track patients’ dates of admission, estimated lengths of stay, discharge plans and destinations, and comments from interprofessional team members. If a patient’s status changes, we update the whiteboard information so that all staff members are aware.
This visual display helps staff focus on a countdown to discharge.
ALC flow sheet and patient information physician order
With the hospitalists and nurses, we have developed a flow sheet to help standardize how we designate people as ALC. We are still in the process of refining and implementing these tools to align with CCO discharge destinations and specialized needs and barriers.
What are your next steps?
Our Patient and Family Advisory Council just passed its one year mark.It is a new initiative, building on the experience and involvement that patients and families can provide.
Involving patients in designing quality improvements has begun, with the first projects including revisions to our Patient Directory and Handbook as well as a needs assessment and recommendations for patient entertainment and education systems.
One of the things we are considering is looking at patient satisfaction and if we’re doing enough for patients going home. We are planning to do follow-up phone calls to see how discharge went and if patients felt they had enough support. Our social worker has reached out to complex patients who were recently discharged to ensure they are transitioning well.
We are promoting that the admission coordinators for organizations that provide eventual residences for these patients (Long-Term Care and attendant care, assisted living programs, retirement homes), come to the hospital and do an assessment of the patients while in hospital, to reduce patients waiting in the hospital for their eventual residential setting.
What would your advice be for other organizations striving to reduce ALC?
- Think openly and creatively about transition and discharge options
- Ensure unified messaging as the interprofessional team listens to and works with patients and families towards discharge
- Take steps to avoid rushed conclusions about Long-Term Care as ‘the only’ option; challenge and acknowledge your own hesitations in enabling and supporting a safe and effective discharge
- Ensure reducing ALC remains a strategic priority with visible leadership support
- Continued vigilance is needed to sustain gains as new and different challenges with ALC emerge
You may also be interested in: Using promising practices to improve ALC rates: Spotlight on Runnymede Healthcare Centre
Do you work on the issue of ALC at your organization? Reach out to Heather Klopp on Quorum or add your questions or comments below.