ORD - ALC Definitions and Overview

ALC Definitions and Overview

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Covered in this topic:

Provincial ALC Definition

ALC Facility Definitions

ALC Specialized Needs & Supports Definitions

The term alternate level of care (ALC) is a clinical designation that identifies patients who no longer require the intensity of resources or services provided in their current settings and who are waiting for ALC.

Provincial ALC Definition

When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in this care setting (Acute, Complex Continuing Care, Mental Health or Rehabilitation), the patient must be designated Alternate Level of Care (ALC)¹ at that time by the physician or her/his delegate. The ALC wait period starts at the time of designation and ends at the time of discharge/transfer to a discharge destination² (or when the patient’s needs or condition changes and the designation of ALC no longer applies).

This will be determined by a physician/delegate, in collaboration with an inter-professional team, when available.

What is ALC not used for?

ALC guidelines are only applicable to active treatment/acute care discharges. ALC is not used for residential care, intermediate/personal care or day care surgery cases.

How is a patient determined as ALC?

Ask the following question: Does the patient still need to be in this hospital? If the answer is NO, then the patient can be identified as ALC.

Who identifies a patient as ALC?

The physician or authorized hospital designate (i.e., Advanced Practice Nurse) is required to make a medical decision to determine when the patient no longer requires acute care services.

Physicians, APNs or physician assistants enter ALC orders in EPR once the patient has been designated as ALC.

When is ALC status identified?

Patient ALC status is often identified through a collaborative interdisciplinary approach (e.g. during interdisciplinary rounds).

When is ALC ordered?

The physician or authorized hospital designate (i.e., APN or physician assistant) should place the ALC order within the same day of making the medical decision that the patient no longer requires acute care services.

Once the order has been accepted, it will be sent to a work queue for the Patient Care Coordinator (PCC) or in-charge nurse to document. An ALC work queue contains a list of active ALC orders to be documented.

When is ALC documented?

The PCC/in-charge nurse should document the ALC order as soon as the destination facility has been confirmed.

Once the order has been documented, the ALC status will be noted in the patient’s electronic chart.

Note 1:

· The patient’s care goals have been met

· Progress has reached a plateaU

· The patient has reached her/his potential in that program/level of care.

· An admission occurs for supportive care because the services are not accessible in the community (e.g. “social admission”)

Note 2:

Discharge/transfer destinations may include, but are not limited to:

· home (with/without services/programs)

· rehabilitation (facility/bed, internal or external), complex continuing care (facility/bed, internal or external),

· transitional care bed (internal or external)

· long term care home,

· group home,

· convalescent care beds,

· palliative care beds,

· retirement home,

· shelter,

· supportive housing.

Final Note:

· The definition does not apply to patients:

· waiting at home,

· waiting in an acute care bed/service for another acute care bed/service (e.g., surgical bed to a medical bed),

· waiting in a tertiary acute care hospital bed for transfer to a non-tertiary acute care hospital bed (e.g., repatriation to community hospital).

ALC Facility Definitions

Unknown
Assigned when a patient’s ALC Discharge Destination is not known, not established or does not exist.

Complex Continuing Care (CCC)
A designated bed providing specialized care to patients who are medically complex, require a hospital stay, regular onsite physician care and assessment, and active management over extended periods of time.

CCC-Low Tolerance Long Duration

Specialized inpatient rehabilitation suitable for individuals in need of a slower-paced program over a longer period of time than is offered in other programs. LTLD is used interchangeably with ”r;slow stream rehab”.

CCC-Non-Low Tolerance Long Duration

This category would include all patients in Complex Continuing Care beds who are not in an LTLD.

Convalescent Care Bed

Provision of care to support the gradual recovery of Health and strength after illness or surgery. Convalescent Care programs provide 24-hour care to people who require specific medical and therapeutic services in a supportive environment for a defined period of time.

Home

Private residence where a patient will live in the community upon discharge from the hospital. Provision of an array of services which enables a patient to live at home, often with the effect of preventing, delaying or substituting for Long-term care or acute care alternatives.

Home with CCAC Services

Patient is discharged home with services provided by a Community Care Access Centre (CCAC) with acts as a local point of contact to co-ordinate community-based nursing and rehabilitation services. CCAC’s also determine eligibility for government-funded home and community support services and admission to a long-term care home

Home with Community Services

Patient is discharged home with community-based services not offered through a CCAC, to support a patient’s ability to live in the community. This may include but is not limited to: day hospital, outpatient programs or clinics, and elder care day programs.

Home without services

Patient is discharged home with no services required.

Long Term Care Bed

A designated bed providing care to meet both the medical and non-medical needs of patients with a chronic illness or disability who require care that is not available in the community.

Mental Health

A designated bed providing therapeutic services to patients with additions, psychological, behavioural or emotional illnesses

MH-Inpatient Detoxification Services

Services designed to facilitate the process whereby an alcohol/drug intoxicated or alcohol/drug dependent person is assisted through the period necessary to eliminate the intoxicating substance, and/or the dependent factors, while keeping the physiological risk to the patient to a minimum.

MH-Inpatient Dependency Treatment Services

Services designed specifically to care for and treat chemical dependency, under a prescribed treatment program.

MH-Inpatient Psychiatry Services

Service provided to patients with psychological, behavioural or emotional illnesses requiring voluntary or involuntary inpatient psychiatric care. This category would include all patients in mental health beds who are not in either detoxification or dependency beds.

Palliative Care Bed - Provision of medical or comfort care to support end of life planning to reduce the severity of a disease or slow its progress. The focus is on quality of life measures rather than providing a cure.

Palliative-Palliative Hospital Placement

Palliative care delivered within a hospital environment.

Palliative-Residential Hospice Care

Specialized residential care to palliative patients.

Rehabilitation Bed

A designated bed providing care aimed at maximizing a patients overall physical, sensory, intellectual, psychological and social functioning levels. This may include the acquisition of special equipment or other resources.

Rehab-Cardiac

Specialized inpatient rehabilitation program for patients with cardiac issues designed to maximize a patient’s overall function through inter-professional clinical expertise.

Rehab-Geriatric

Specialized inpatient rehabilitation program for geriatric patients (age as defined by the specific program), designed to maximize a patient’s overall function through inter-professional clinical expertise.

Rehab-Low Tolerance Long Duration Rehabilitation

Rehab-Musculoskeletal (MSK)

Specialized inpatient rehabilitation program for patients with musculoskeletal issues, designed to maximize a patient’s overall function through inter-professional clinical expertise. This may include but is not limited to: arthritis, osteoporosis and bone cancer.

Rehab-Neurological

Specialized inpatient rehabilitation program for patients with neurologically related impairments, designed to maximize a patient’s overall function through inter-professional clinical expertise. This may include but is not limited to: acquired brain injury (ABI), stroke, spinal cord injury and generalized neurological rehabilitation (e.g. degenerative neurological conditions such as Parkinson’s and Multiple Sclerosis).

Rehab-Other Rehabilitation

Non-Specialized inpatient rehabilitation program for patients not captured in the above categories, designed to maximize a patient’s overall function through inter-professional clinical expertise.

Supervised or Assisted Living

Provision of care for patients who are able to mobilize independently but who may require assistance with activities of daily living

Retirement Home

A multi-unit residential facility providing optional services such as meals, housekeeping, recreation activities and personal support.

Shelters

Temporary emergency housing for individuals in crisis or without other accommodations. This includes but is not limited to: homeless patients and victims of domestic violence.

Subsidized Housing

Government supported accommodation for people with low to moderate incomes.

Supportive Housing / Group Homes / Assisted Living

Accommodation with services provided to an individual with chronic or complex needs as a means of maintaining them in the community. These services may include but are not limited to: supervision, personal support, and counselling.

Unexpected Discharge or Transfer

Patient is discharged or transferred to a destination other then the intended ALC Discharge Destination (E.g. patient is discharged against medical advice – AMA, patient is repatriated to another facility to continue ALC wait, etc)

ALC Specialized Needs & Supports Definitions

Bariatric Requirements (BA)

Services designed to provide care for patients diagnosed with obesity. This includes but is not limited to: oversized beds, larger doorways, access to specialized equipment.

Barrier

The specialized care needs/supports of the patient required at the ALC Discharge Destination that are preventing or delaying discharge.

Behavioral Requirements (BE)

1:1 Support: Services designed to provide care to patients identified by the physician and/or delegate to be requiring an elevated level of support, whereby one (or more) staff person(s) is assigned to be within close physical proximity to the patient for a period of time while maintaining constant visual observation. This may include one-to-one support for the entire duration of the patient stay, or for a limited time.

Aggressive Behaviors: Services designed to provide care for patients who exhibit aggressive behaviors including but not limited to; pushing, spitting, hitting, property destruction, etc.

Sexualized Behaviors: Services designed to provide care for patients who exhibit sexualized behaviors including but not limited to; inappropriate touching or grabbing, exposure of private parts, sexualized conversation, etc.

Unspecified: Services designed to provide care for patients who have behavioral requirements that do not fall under the category of 1:1 support, aggressive or sexualized behaviours. This may include, but is not limited to; impulsivity, hyperactivity, self-injury, etc. Services may also be outpatient or community-based.

Development Requirements

Services designed to provide care for patients who have development requirements including but not limited to autism spectrum disorder (ASD), fetal alcohol spectrum disorder (FASD), attention deficit hyperactivity disorder (ADHD), learning disabilities, etc. This may include outpatient or community-based services.

Dialysis Requirements (DL)

Services designed to provide care for patients with renal impairment necessitating hemodialysis or peritoneal dialysis.

Equipment / Structural Requirements (*no Bariatrics) (ES)

Modifications to the discharge destination required prior to the patient's discharge. This would include equipment installation (e.g. lifts and grab bars) and structural changes (e.g. widening of doors and building ramps). This category excludes needs for bariatric patients.

Feeding Requirements (FD)

Service designed to provide a patient with a non-oral form of nutrition. Routes may include enteral (e.g. gastric tube or nasogastric tube), or total parenteral nutrition (TPN).

Infection Control / Isolation Requirements (IC)

Isolation: Services designed to provide care for patients requiring isolation or negative ventilation accommodations due to an infectious or immune-compromised condition.

Outbreak at Discharge Destination: When the discharge of a patient designated ALC is prevented or delayed due to an outbreak occurring at the facility in which the patient is expected to be discharged to. Note: Barrier Only

Outbreak at Facility: When the discharge of a patient designated ALC is prevented or delayed due to an outbreak occurring at the facility in which the patient currently resides. Note: Barrier Only

Mechanical Ventilation Requirements (MV)

Services designed to provide care for a patient who is mechanically ventilated

Medications/Labs/Therapy Requirements (ML)

Services may include but are not limited to: chemotherapy, radiation therapy, pain control, intravenous medication administration, high-cost/difficult-access medications, ongoing lab work and monitoring of medication levels.

Mental Health Requirements (MH)

Addictions: Services designed to provide care for patients who have an addiction including but not limited to; drugs (street, prescription), alcohol, tobacco, etc.

Concurrent Disorders: Services designed to provide care for patients who have a ‘concurrent disorders’ meaning that a patient has both a psychiatric diagnosis and a substance abuse diagnosis (which may include both drugs and alcohol).

Unspecified: Services designed to provide care for patients who have mental health requirements that do not fall under the category of concurrent disorders or addictions. This may include, but is not limited to; eating disorders, mood disorders, personality disorders, bipolar disorder, schizophrenia, etc.

Need

The specialized care needs/support of the patient required at the ALC Discharge Destination that are not preventing or are not known to be preventing discharge.

Neurological Requirements (NE)

Acquired Brain Injury: Services designed to provide care for patients who have an Acquired Brain Injury including but not limited to; traumatic and non-traumatic brain injury.

Traumatic Brain Injury: A traumatic brain injury can be classed as an open or closed injury. A closed injury is caused when the brain is bounced around in the skull due to a blow to the head or severe shaking such as in a road traffic accident. A closed motion can cause tearing, shearing or stretching of the brain tissue. An open injury occurs when an object such as a bullet, fractures the skull and enters the brain.

Non-Traumatic Brain Injury: A non-traumatic injury is an injury that does not occur as a result of trauma. This includes stroke, tumours, infectious diseases, lack of oxygen or toxicity.

Unspecified: Services designed to provide care for patients who have neurological impairments that do not fall under the category acquired brain injury including but not limited to; impairments of cognition, function and development. This may include outpatient or community-based services.

Respiratory Requirements (*excludes ventilation) (RE)

Services designed to provide care for a patient with respiratory impairment necessitating care. This may include but is not limited to: tracheostomy, oxygen therapy, bi-PAP / CPAP, and suctioning. This category excludes mechanical ventilation.

Social Requirements

Financial Constraints: Services designed to support patients who experience financial constraints including but not limited to; unemployment, job insecurity, fixed incomes, or who are receiving social assistance, etc.

Housing/Homelessness: Services designed for patients who experience housing limitations or have homelessness issues. This may include but is not limited to patients who are; inadequately or insecurely housed, utilizing shelter services or subsidized housing, or have no fixed address, etc.

Rooflessness: Living without a shelter of any kind, (e.g. sleeping outdoors) often called absolute homelessness;

Houselessness: Living in temporary facilities, (e.g. institutional shelters or health care facilities) often called sheltered or transitional homelessness;

Insecurely Housed: Living precariously, (e.g. in insecure tenancies, close to eviction, in an unsafe situation, or subject to domestic violence) includes those who are among the hidden homeless or sometimes termed relative homeless; and

Inadequately Housed: Living in a home that does not meet basic standards (e.g. in substandard housing, suffering mold infestation, overcrowding, inaccessible for the person or family) includes people who are in core housing need.

Wound Care Requirements (WC)

Services designed to provide care for patients with compromised skin or tissue integrity. This may include but is not limited to care of: amputations or prosthetics, ostomy sites, VAC therapy, surgical wounds or pressure ulcer dressings.