Confronting the Alternate Level of Care (ALC) Crisis with a Multifaceted Policy Lens

Dual demands for increased provision of acute episodic care in hospital and chronic care in the community have contributed to an ALC crisis in Canadian hospitals, where large numbers of patients are boarded in acute-care beds rather than in environments more appropriate for their required level of care. Addressing this crisis will be one of the most profound challenges facing provincial health systems in Canada over the coming decades. This paper outlines the magnitude and complexity of confronting this growing crisis as well as defining a paradigm through which to explore and implement policy solutions along the entire continuum of challenges. ALC as an administrative designation aggregates diverse groups of patients covering a wide spectrum of demographic variables, medical diagnoses, social circumstances, discharge destinations and other characteristics, all of which can affect how and when ALC is coded. It is itself a significant challenge to collect consistent, accurate and adequately granular data to inform the design and implementation of policy reforms. With this in mind, a dominant association between advanced age and markedly higher ALC rates needs to be acknowledged and highlights that solutions to the ALC crisis will be significantly interwoven with addressing previously described challenges for the overall health system with an aging population. Clinically and operationally, ALC is a complex health-system issue that reflects and presents challenges from admission, throughout a patient’s hospital stay and after discharge. This paper outlines a holistic approach to categorizing policy interventions that address obstacles along this continuum, describing potential interventions in each phase. To achieve success, policy approaches must incorporate multi-faceted interventions into the overall context and systematize them to prevent, mitigate the burdens of, and improve the management of ALC.