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					  Central East LHIN
ALC Task Group Report

                        March 2008




                                 1
ALC Background
•   An ALC patient is one that has finished the acute care phase of their
    treatment but remains in an acute care bed in hospital.

•   This classification occurs when the patient's physician gives an order to
    change the level-of-care from acute care and requests a transfer for the
    patient.

•   These patients then await placement to an alternate setting:
    Examples include patients waiting for:
     • Transfer to a rehabilitation unit
     • Transfer to a palliative care unit or hospice
     • Transfer to a Long-Term Care Home
     • Transfer to a Complex Continuing Care unit
     • Transfer to Sub-acute or Convalescent Care
     • Supportive housing or other accommodation to be arranged
     • Home care services to be arranged
     • Transportation to be arranged


                                                                                2
Alternate Level of Care
• Sometimes a patient is admitted as an ALC patient because
  alternate care is not available

• A high number of ALC patient or patient days of stay may indicate
  inefficient use of acute care beds, lack of access to long-term or
  rehab care, and/or lack of community support services

• ALC is a broad and complex issue which represents regional and
  system-level problems related to integration, capacity and patient
  flow efficiencies

• High rates of ALC increase emergency and surgical wait times




                                                                       3
Central East’s ALC Problem
How big is this problem?

                                                                                                    % ALC
                                                                                            Avera   Days of   % ALC
                                                                                              ge     Total    Days of
Hosp                                                      Total    Total Total ALC ALC       ALC    Days in   All ALC
Number   Hospital Name                                   Cases     Days ALOS Cases Days     LOS      Site       Days
  3932   LAKERIDGE HEALTH CORPORATION-OSHAWA SITE        16,567   91,079 5.5 892 11,007      12.3   12.1%      18.1%
  1768   PETERBOROUGH REGIONAL HEALTH CENTRE             14,385   94,013 6.5 321 9,586       29.9   10.2%      15.8%
  4152   SCARBOROUGH HOSPITAL (THE)-SCAR.GEN.SITE        18,652   102,536 5.5 324 6,332      19.5    6.2%      10.4%
  1893   ROSS MEMORIAL HOSPITAL                           4,714   35,376 7.5 288 6,285       21.8   17.8%      10.4%
  3860   NORTHUMBERLAND HILLS HOSPITAL                    3,823   23,174 6.1 314 5,313       16.9   22.9%      8.8%
  1597   CAMPBELLFORD MEMORIAL HOSPITAL                   1,106   12,017 10.9 73 4,890       67.0   40.7%      8.1%
  4014   ROUGE VALLEY HEALTH SYSTEM-AJAX SITE             8,066   37,687 4.7 299 4,564       15.3   12.1%      7.5%
  4154   SCARBOROUGH HOSPITAL (THE)-GRACE SITE           12,951   67,085 5.2 202 4,406       21.8    6.6%      7.3%
  3943   ROUGE VALLEY HEALTH SYSTEM-CENTENARY            14,311   70,586 4.9 280 3,483       12.4    4.9%      5.7%
  4008   LAKERIDGE HEALTH CORPORATION-BOWMANVILLE         2,481   16,722 6.7 285 2,808       9.9    16.8%      4.6%
  4005   LAKERIDGE HEALTH CORPORATION-PORT PERRY          1,716    8,134 4.7 130 1,652       12.7   20.3%      2.7%
  3737   HALIBURTON HIGHLANDS HLTH SERV CORP-HALI          486     4,188 8.6    11  366      33.3    8.7%      0.6%
                                       Total - ALL Cases 99,258   562,597 5.7 3419 60,692    17.8   10.8%     100.0%




                                                                                                              4
Central East’s ALC Problem
What is the relative size of this problem?

The total number of ALC Days has increased from 40,845
in Fiscal 2004-2005 to 60,692 as of year-end Fiscal 2006-
2007.

       60,692 ALC Bed Days = 166.3 Bed Equivalents
        365 Days in a Year
                           OR
                1 *Ross Memorial Hospital
             (*167 Average Acute Beds Staffed and Operating)




                                                               5
ALC Task Group
• Formed in May 2007 upon invitation of interest from CE
  LHIN; has met over twenty times in the past 10 months

• Broad and inclusive Membership representing hospitals,
  CCAC, long term care homes, and community services
  as well as across-LHIN geographic representation

• Two days Project Management training (with LHIN) held
  in August 2007




                                                           6
ALC Task Group Membership
Glyn Boatswain : Vice-Chair   Rouge Valley Health System
Janet Burn                    Northumberland Hills Hospital
Judy Byrdine: Admin Support   Whitby Mental Health Centre
Sharon Chapman-Sheehan        CE CCAC Peterborough
Marshall Elliott              Community Living Kawartha Lakes
Melanie Flood                 Haliburton Highlands Health Services
Carol Gordon                  Kawartha Participation Projects
Brian Laundry                 CE LHIN
Andrew Masden                 CE LHIN
Craig McCleary                Canadian Red Cross, Community Health
Shailesh Nadkarni             Peterborough Regional Health Centre
Sheila Neuburger: Chair       Whitby Mental Health Centre
Carol Smith Romeril           Ross Memorial Hospital
Lesreen Romain                Victorian Order of Nurses
Diane Southwell               Campbellford Memorial Hospital
Karen Southwell               Lakeridge Health Corporation
Nancy Veloso                  The Scarborough Hospital
Joni Wilson                   St. Joseph’s At Fleming



                                                                     7
ALC Task Group
Purpose
 1) Environmental Scan:
    To determine the underlying causes and
    contributing factors to ALC issues in Central East,
    and
 2) Action Plan:
    To recommend some practical ways that can be
     implemented locally to help alleviate and/or
     eliminate the ALC pressures in Central East.




                                                          8
Investigative Process

• This is a provincial issue and the ALC Task Group
  reviewed several reports from throughout Ontario
• Received presentations re: various initiatives/projects
  (e.g. Flo Collaborative) and services (e.g. CCAC)
• Developed a Process Map and requested that every
  hospital in CE identify operational barriers that they
  experience at the front-lines
• Collected ALC and socio-demographic data (through
  LHIN) e.g # ALC beds, discharge destinations, LTCH
  vacancy rates and waiting lists, etc.

                                                            9
            Care Continuum
                                ALC
  ALC
                             Discharge
Determin-
                               Ready
  ation




                                         ALC Task Group, CE LHIN Mar 2008
Process Map
• ALC Task Group scope of work started with ALC
  designation (by physician) to discharge from hospital =
  B to C on Process Map Care Continuum (non-acute)
• As a systems issue, realized that had to consider from
  presentation at hospital and acute admission (A on
  Process Map) and optimal level-of-care discharge
  destination (D on Process Map) which extended scope
  of work and recommendations
• Both health human resource issues and ALC information
  management and performance measurements cross all
  processes (E and F on Process Map)


                                                       11
Draft Recommendations – March/08

 There are fifty-eight Sub-recommendations drafted
 under six overall directions (each one corresponds to
 Process Map A - F).

 The six overall Recommendations are described below
 with some examples of the Sub-recommendations
 currently being considered by the ALC Task Group.




                                                         12
Draft Recommendations
1. Ensure the early identification of people at high-risk to be
   designated ALC and the early intervention of community
   supports/services. (Process Map: A)

Sub-recommendations include:
   i.   Continue and expand the presence of Geriatric Emergency
        Management Nurses in emergency departments
   ii. Implement a standardized risk screening tool (physical &
        psycho-social needs) to identify those most at-risk to be
        designated ALC, and repeat screening during acute care
        hospitalization
   iii. Extend CCAC service maximums for home nursing,
        homemaking and personal support to delay LTCH admission


                                                                    13
            Care Continuum
                                ALC
  ALC
                             Discharge
Determin-
                               Ready
  ation




                                         ALC Task Group, CE LHIN Mar 2008
Draft Recommendations (cont’d)
2. Objectively assess optimal level of care and
   improve patient flow to appropriate discharge
   destination. (Process Map: B to C)
Sub-recommendations include:
   i.   Establish clear expectations and accountabilities for
        ALC designation
   ii. Develop a consistent triage process to delineate
        levels of care (e.g. home with supports, supportive
        housing, LTCH, palliative care, etc.)
   iii. Provide in-hospital activation/exercise program to
        maintain optimal functionality and mental wellness
        while waiting for placement
                                                            15
Draft Recommendations (cont’d)
3. Improve system access and smooth transitions
   across the continuum of care including enhanced
   communication and education. (Process Map: B, C, D)
Sub-recommendations include:
   i.   Establish benchmarks and timelines from ALC designation
        and referral to bed admission
   ii. Expand capacity in existing LTCHs by offering interim beds
        and “over-bedding” whenever possible
   iii. Provide behavioural support units within LTC facilities that
        include short-stay transitional beds for people with temporary
        cognitive decline and permanent beds for people with ongoing
        behavioural needs
   iv. Increase the number of Psychogeriatric Resource Consultants


                                                                    16
Draft Recommendations (cont’d)
4. Build community capacity and linkages and
   support independence through care in the
   community. (Process Map: D)

Sub-recommendations include:

  i.     Expand multi-disciplinary Psychogeriatric Outreach Teams
  ii.    Increase supportive housing, rent geared to income and
         assisted living options including Attendant Care Outreach
  iii.   Create and enhance community support services
  iv.    Subsidize fees for community support services for low-income
         seniors and people with physical disabilities


                                                                    17
            Care Continuum
                                ALC
  ALC
                             Discharge
Determin-
                               Ready
  ation




                                         ALC Task Group, CE LHIN Mar 2008
Draft Recommendations (cont’d)
5. Develop a Health Human Resources Strategy
   including enhanced professional education as a
   critical enabler for all of the ALC Task Group
   recommendations.         (Process Map: E)
Sub-recommendations include:
   i.   Continue enhanced skills training for both
        Registered and non-Registered staff in LTCHs
   ii. Investigate Telehealth to increase access to
        consultation with specialized resources
   iii. Hire Nurse Practitioners to work in conjunction with
        Medical Directors in LTCHs


                                                               19
Draft Recommendations (cont’d)
6. Monitor and track ALC performance measures for
   system evaluation and planning. (Process Map: F)

Sub-recommendations include:
   i.     Implement a standardized database for ALC designations and
          discharge destinations
   ii.    Collect and track ALC information for local analysis and
          planning on a monthly basis
   iii.   Create a CE LHIN ALC Implementation Committee to oversee
          and monitor implementation of the approved
          recommendations and to track data for planning purposes



                                                                  20
Next Steps
• Presenting draft recommendations to Collaboratives for
  input and feedback over the next 3 weeks
• Consulting with the CE LHIN Emergency Department
  Task Group, Rehabilitation Task Group, Seamless Care
  for Seniors Health Interest Network, Mental Health and
  Addictions Health Interest Network and CEEC
• ALC Task Group is prioritizing recommendations that
  are expected to have the most positive impact on the
  system in CE LHIN and will direct next steps for
  implementation
• Presenting Final Report to CE LHIN Board of Directors
  in May/June 2008
                                                       21
Request for Feedback
• Do these recommendations address the
  key ALC issues in your community?

• Are we missing anything?

• Any additional comments or questions?



                                          22

				
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