Mississauga Halton LHIN is using a strategic, multi-pronged approach to address the Alternate Level of Care (ALC) issue in their region.
High ALC rates are a symptom of a system-wide problem, where patients who no longer require acute care are unable to transition to a more appropriate setting due to capacity issues, complex health and social needs and various other reasons.
Health Quality Ontario had a chance to catch up with David Fry, Vice President of Home and Community Care and Carmela Costiniuk, ALC Regional Director at Mississauga Halton LHIN to learn more about their ALC approach.
Tackling the ALC issue at the LHIN level is a big challenge. How did you start?
In July 2017, we brought together a small Patient Access and Flow Steering Committee with regional leaders from home and community care, community support services, senior leaders from our two local hospitals and our LHIN. We included representation from our Strategy Management Office in the committee who was very helpful in setting our course and terms. I (David) chair the bi-weekly Steering Committee meetings along with two hospital co-leads, which helps with buy-in and support.
Early on, we established guiding principles, clear governance, terms of reference, a strategic work plan, clear deliverables, and data measures we’d use to track our progress.
We decided that the focus of our committee should be on improving day-to-day operations in the health care system by using best practices and processes. We wanted our work to be very practical and tactical.
At the same time, both of our local hospitals initiated an assessment utilizing the ALC Avoidance Framework developed by the Toronto Central LHIN, which helped to build the foundation for our strategic work plan.
What does your committees’ strategic work plan include?
Our ALC Avoidance, Management and Flow Work Plan includes three workstreams that are aligned with best practices in the ALC Avoidance Framework.
1: ALC prevention in the community:
The goal of this workstream is to identify patients in the community at risk for being designated ALC to prevent emergency department (ED) visits and hospital admissions.
Activities include:
- Improving assessments: Community care coordinators incorporate the DIVERT (Detection of Indicators and Vulnerabilities for Emergency Room Trips) and TUG (Timed Up and Go) assessments from Inter-RAI into their overall assessments of home care patients. Care plans are put in place based on the assessments to mitigate risk for vulnerable patients.
- Attending to specific populations: A Nurse Practitioner/Registered Nurse is assigned to patients with a DIVERT score of 5/6 and a diagnosis of COPD/CHF. A disease specific pathway has been developed to improve outcomes by incorporating chronic disease management strategies, screener tools, and an escalation process to mitigate risks and prevent a visit to ED. This is currently a test model of care.
- Providing bedded restorative programs: Nurses follow patients from the community to the hospital and back with the goal of sustaining the patients in the community for as long as possible. The services are provided in the patient’s home.
2. Early identification of at-risk hospital patients:
The goal of this workstream is to identify patients in the ED at risk of being designated ALC.
Activities include:
- Using a test model of care for Quick Response Team (QRT) in EDs. The intent is to have this led by the ALC Response Team (ART) in the hospital and consult as required.
- Standardizing ALC designation practices
3. Transitioning ALC patients out of hospital:
The goal of this workstream is to transition ALC patients from the hospital to the community or Long-Term Care (LTC).
Activities include:
- Managing facility choice lists for patients awaiting LTC in hospital: The ART leads have been instrumental in accessing and consulting with patients about their LTC choices that may be out of region. For example, idle bed lists from neighboring LHINs are reviewed daily and transitional beds or other interim options are considered as patients await LTC.
- Identifying patients appropriate community-based programs: These include Bridges to Care and My Way Home (more on these programs below).
- Minimizing time to transition patients to post acute destinations by escalating barriers in real time so that there are no delays.
See the ALC Management Graphic and Quarterly Dashboard for more information.
Who is involved in implementing the three workstreams?
The first workstream will be led by the home and community care coordinator in the community assigned to the pilot.
The second and third workstreams are being implemented by the entire discharge planning team including discharge planners, ALC Response Team (ART) leads, home and community care and consulting with physicians, nursing and other staff as appropriate.
We created and use a weekly operational dashboard with specific indicators that managers, directors and front-line leaders can track trends such as changes in ALC designations. Both senior leaders from our two local hospitals have shared feedback that the dashboard has been very useful.
What has made the biggest impact on your ALC rates?
Our LHIN currently has 25% fewer LTC beds per senior than the provincial average. This makes effective transitions more difficult and puts pressures on hospitals.
Our short-term transitional care models, Bridges to Care and My Way Home programs, have made the biggest impact on being able to effectively transition patients out of hospital.
Bridges to Care
The program is a partnership between the Mississauga Halton LHIN, Halton Healthcare and Trillium Health Partners and funded by the Ministry of Health. It provides patients with short-term supports in the community from personal support workers for up to 60 days. There are 37 beds available across several retirement homes, LTC homes, and assisted living facilities. The program can also be available in personal dwellings.
After 60 days, patients will transition to a LTC Home or explore options for remaining in a personal dwelling or retirement home with in-home supports.
Within the first year of the program, Trillium Health Partners reported that the Bridges to Care program had saved 18,557 patient days, the equivalent to freeing up one 50 bed unit for more than one year.
My Way Home
Complex patients leaving the hospital, regardless of their final destination, are eligible to receive pre-hospital discharge occupational therapy (OT) and Rapid Response Nurse (RRN) services, as well as enhanced in-home personal support, OT, physiotherapy (PT), and RRN services for up to 60 days.
Evaluation of the program demonstrated that patients who received OT and PT services in the first month post discharge were significantly less likely to return to the ED within 30 days.
What are your next steps?
Now that our Steering Committee has been in operation for about a year, we are hoping to expand our membership to include the patient voice. As we continue to work on our Work Plan, we’re hoping to see even more improvements in our first workstream (ALC prevention in the community) this coming year.
Once we’ve made strides in transitioning patients out of the hospital in a reasonable timeframe, the new generation of ALC will look differently in terms of hospital length of stay. The question we’re asking ourselves now is: How do we work even more upstream – how do we find at-risk patients in the community through primary care, especially as it relates to the Health Links Approach to Care? What are the flags to indicate that a patient is at risk for going to the ED and being designated ALC? These issues occur before patients access home and community care.
There is a pan-LHIN initiative starting that will develop guiding principles for ALC and standardize approaches as much as possible while acknowledging the difference needs of each LHIN. The first meeting is set for September.
What advice would you give to other LHINs about addressing the ALC issue?
Take the time to analyze the existing patients and trends in your LHIN to create targeted strategies and work plans. Every LHIN is different and there is no cookie cutter approach.
Use the ALC Avoidance Framework because it’s the best possible evidence we have. It also garners credibility with hospital partners when anchored in this approach.
Although it takes time and hard work, collaborate with a Steering Committee with expertise across all sectors and spend time to create clear governance and terms of reference. The relationship building you do up front will reap benefits in the long haul.
Do you work on the issue of ALC at your LHIN? Reach out to Carmela Costiniuk on Quorum or add your questions or comments below.