Runnymede Healthcare Centre has made significant improvements in reducing their Alternate Level of Care (ALC) rate from 10.37 (rate per 100 inpatient days) in 2017/18 to 4.68 in 2018/19 as per their Quality Improvement Plan (QIP).
The ALC rate is a symptom of a system wide problem, where patients who no longer require hospital or rehabilitation inpatient care are unable to transition to a more appropriate setting due to capacity issues and various other reasons.
To learn how they achieved this success, Health Quality Ontario had a chance to catch up with Lisa O’Drowsky, Director of Quality and Risk Management, Lisa Dreher, Manager of Access and Flow, and Luba Kelebay, Manager of Pharmacy and Allied Health at Runnymede Healthcare Centre.
Reducing ALC rates is often a big challenge for hospitals. What led to your recent improvement?
As a hospital for people with complex continuing care and rehab needs, we work closely with our acute care and community-based partners to improve communication and help patients transition from acute care to Runnymede and from Runnymede back to the community.
We are also a part of the Toronto Central (TC) LHIN ALC working group where promising practices are shared. The group has been helpful in exploring and sharing improvements, and working together to improve reintegration. One useful tool the working group has developed is the TC LHIN ALC Framework.
Runnymede Healthcare Centre has significantly reduced their ALC rate as per their 2018/19 Quality Improvement Plan (QIP).
Can you describe the strategies you use to improve patient flow and reduce ALC rates?
There are four strategies that have made the biggest impact on improving patient flow and reducing ALC rates:
Early identification of people at risk for being designated ALC
- For inpatients who are at risk of being designated ALC, we have begun to hold weekly avoidance rounds whereby we set goals to ensure transition to the community. We may employ early intervention escalation meetings as well as a Transitional Coordinator to support patients and families through the process of exploring alternate destinations.
Clustering ALC patients in a short stay unit
- We have begun clustering ALC patients onto a transitional, short stay unit. This allows us to design more appropriate programming for these patients, while considering the needs of more vulnerable ALC patients, like those with responsive behaviours.
- We are currently looking at appropriate care pathways for this unit and are working with our partner hospitals as well as the TC LHIN to design program guidelines for this population.
Restructuring roles and processes in Runnymede to improve internal flow
- First off, we changed our process and started interviewing patients prior to admission to Runnymede when a discharge plan may not be appropriately communicated on a referral. We became aware that some rehab hospitals were visiting acute care hospitals (for example patient flow coordinators from Providence visiting St. Michael’s Hospital rehab patients) and wanted to mirror this practice. This helps us confirm if a patient and family have explored a community transitional plan and provide support before they even step foot into our hospital.
- We intervened to work with the acute hospital team so that reintegration plans could be solidified prior to admission to Runnymede. This helped the family adjust expectations to the level of care that would be provided at Runnymede. In the current system, there are alternatives for patients expected to go to long-term care that are available while in acute care, but not available in complex continuing care and rehab.
- The second thing we did was merge departments responsible for admissions/patient flow and discharges/social work (social workers are the discharge planners at Runnymede). The new department is now called Access and Flow. With the merged departments, we discovered many opportunities for improvement (see next section for work done since we merged).
Developing information materials for patients and staff
We realized that staff and patients were not always aware of community supports available that could help with patients’ health and rehab goals upon discharge.
- We created patient/family information packets that outlined discharge destination options and made sure to include key contacts. As well, we customized each packet to that patient.
- Further, we hosted a discharge information session for families and patients and highlighted community resources. We plan to do this on a continual basis for our rehab patients, as it was a great success.
We also noticed that staff members were often distressed about how patients would cope in the community after discharge.
- We brought in ethicists from the Centre for Clinical Ethics to discuss staff moral distress and to help staff reframe their thinking about what appropriate discharge can look like for patients.
- For example, if a patient had been managing at a lower functioning level prior to admission, this level of functioning can be acceptable upon discharge assuming the patient is comfortable with it as well.
What advice do you have for other hospitals looking to reduce ALC rates?
Work with your peers, your partners and your LHIN to share best practices. Look within your own organization to recognize and resolve silos and parallel processes that get in the way.
ALC avoidance will be your biggest success and it is only possible through strong partnerships with community resources.
If you are thinking of creating an ALC unit, use the ALC Guidelines. Find the right balance so that patients understand that the care is transitional, but are also preparing for LTC. Using the guidelines across peer hospitals will be helpful in forwarding improvements and level setting patient expectations.
What are your next steps?
In the 2018-19 fiscal year, our communications team has been hosting information sessions targeting patients and family members to address their knowledge gaps. Patient family engagement committee meetings are attended to learn what our patients and families would like to know more about. A common response is the need for information on available resources following discharge.
In response, a post-discharge information session for family
members that highlighted community resources was conducted. This was been a successful
approach and will be done on a continual basis for our rehab patients.
To further strengthen the ALC avoidance strategy we are looking at revising our discharge policy to ensure there is a clear escalation process, with targets and goals. This will help us ensure that if necessary, LTC plans are in place in the overall reintegration plan back to the community.
You may also be interested in: How do you impact ALC in a small rural hospital? Spotlight on South Huron Hospital
Do you work on the issue of ALC at your organization? Add your questions or comments below.