[State of knowledge: organization of care and services related to alternate levels of care (ALC)]

David I, Saury S
Record ID 32018001251
Original Title: État des connaissances: organisation des soins et services en lien avec les niveaux de soins alternatifs (NSA)
Authors' objectives: Both in Québec and internationally, the situation of users waiting for ALC uncovers issues related to their complex clinical needs, further compounded by issues of accessibility, integration, continuity and coordination of care and services between the various levels of the care network. To this are added important issues related to the efficiency of health and social services systems. The main objective of this report is to document practices in Canada and internationally with a view to supporting MSSS in its efforts to reduce the number of people waiting for ALC while they are in hospital. A state-of-knowledge report was thus produced, documenting governmental, organizational and clinical practices prior to, during and after hospitalization, as well as the monitoring and prediction methods used, in five health care systems, i.e. Ontario, British Columbia, Australia, France and the United Kingdom. These systems were selected, in collaboration with the project requestor, because their practices potentially offer promise in managing ALCs or because they address certain key concepts related to ALCs, and due to relevant information being available.
Authors' results and conclusions: (RESULTS): A certain variability in the ALC concept can be observed from the outset. The definition of ALC used in most Canadian provinces and territories is the one proposed by the Canadian Institute for Health Information (CIHI). At the international level, this concept is not always used, or its use is not consistent. CIHI suggests that facilities codify alternate levels of care according to the reason leading to the designation [CIHI, 2016] and not on the basis of the intended destination, the latter currently being the case in Québec. This codification allows for a quick clinical overview of users waiting for ALC but does not limit the various possible destinations available to them. ALCs can also be addressed in terms of “causes and effects,” as proposed by Micallef and collaborators [2020]. Thus, there may be “causes” that explain why users end up as ALC patients (e.g. social isolation, inadequate social services, delays in discharge planning, insufficient beds in rehabilitation and in long-term care facilities). Once users are waiting for ALC, “effects” can be observed (e.g. overflowing emergency rooms, higher costs). Decision-makers who adopt this perspective may opt to focus more on the causes or the effects of the situation. The literature reviewed also showed that, when working to reduce ALCs, the documented health care systems consider both ALC and other indicators (e.g. average length of stay, rehospitalization rate). This information can point to local solutions (e.g. adding beds in a specific facility) or governmental ones (e.g. additional financing), depending on the analyses that are carried out. In terms of government practices, the literature consulted addressed three complementary themes linked to the case management of users waiting for ALC, i.e. governance, financing and flow management. With respect to governance, ALC-related responsibilities need to be properly defined and distributed across national, regional and local levels. Several health care systems receive ALC case management support from organizations. Various financing mechanisms that can affect the ALC issue are implemented by the health care systems consulted. Some mechanisms are intended to increase the efficiency of hospital services, while others seek instead to support home or community services. Patient flow management, which focuses on managing the number of users served, is promoted in two of the documented health care systems. The approach developed in Australia takes the view that interruptions in patient flow result from multiple causes. In the UK, flow management is considered important for the patient experience, clinical safety and assessment of staff workload. According to NHS Improvement [2017], flow management also leads to an improved ability to address any new pressures on the health care system that might arise. With regards to organizational and clinical practices, these are grouped according to the care and services continuum, i.e. prior to, during or after hospitalization. The importance of taking upstream action to address ALCs is stressed in the literature analyzed. In several health care systems, home hospitalization is presented as a practice that can potentially reduce the number of users waiting for ALC or shorten their hospital stay. Several documented health care systems referred to strengthening or enhancing such services as occupational therapy and social work during the hospital stay. A number of the documented health care systems also mentioned the creation of programs specifically designed to meet the needs of older adults, both within hospitals and in the community. In addition to the various governmental, organizational and clinical practices presented above, the literature analyzed also revealed other relevant considerations regarding ALC. Firstly, the literature suggests that changes in clinical practice require a coherent, coordinated global approach to managing change and implementation. Another consideration mentioned in the literature is that the various stakeholders involved in the case management of users waiting for ALC have different mandates, be they optimizing the users’ health or taking care of managing a facility. This can lead to differences of opinion and even tensions in understanding ALCs and the actions that must be undertaken to reduce them. (LIMITATIONS): There are several limitations to this state-of-knowledge report. The variability around the ALC concept is especially apparent in the terminological differences found at the international level – differences that endangered identifying and selecting relevant documents. In addition, the interpretation of the overall results is influenced by the different structural, financial and organizational contexts of the care and services in which ALC practices occur within each of the documented health care systems. Other practices, not identified in this work, may help to shorten hospitalizations in specific populations that are at greater risk of a stay in ALC. As a result, it may prove difficult to interpret the impact of ALC practices unless the context and other current practices in the care and services continuum are taken into consideration. Furthermore, the COVID-19 pandemic has forced facilities in the health and social services network to be highly creative in order to free up hospital beds, including those occupied by users waiting for ALC [MSSS, 2020]. This public health crisis could lead to long-term changes in the way the health and social services are offered. It should be noted, however, that no data specific to the COVID-19 context have been incorporated into this state-of-knowledge report. CONCLUSION: This state-of-knowledge report can serve as a basis for other work related to users waiting for ALC in Québec. Various avenues need to be considered. A review of the literature on a specific topic (e.g. hospitals at home, support for informal caregivers, flow or transition management) would allow for a more complete understanding of the actions that could be undertaken in Québec. In addition, a state-of-practice report supported by contextual data from several facilities could be used to target specific issues and to document practices that offer promise in the Québec context.
Authors' methods: For the literature search, the websites of organizations, learned societies and government agencies of the selected health care systems were consulted. Keywords such as alternate level of care, delayed discharge or bed blockers were used. Consideration was thus given to all practices aimed at optimizing ALC management before, during and after hospitalization. A total of 86 documents were analyzed, including 11 primary research studies, 6 literature reviews, 2 theses, 31 references from government sources (websites and documents) and 36 publications by learned societies. An analytical narrative review was first carried out for each of the five selected health care systems. All identified practices were then combined to extract the key findings. A few other considerations that emerged from the analysis are also briefly outlined.
Project Status: Completed
Year Published: 2021
English language abstract: An English language summary is available
Publication Type: Other
Country: Canada
Province: Quebec
MeSH Terms
  • Hospitalization
  • Patient Discharge
  • Length of Stay
  • Patient Transfer
  • Health Services for the Aged
  • Frail Elderly
  • Bed Occupancy
  • Waiting Lists
  • Aged
  • Alternate Levels of Care
Organisation Name: Institut national d'excellence en sante et en services sociaux
Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369
Contact Name: demande@inesss.qc.ca
Contact Email: demande@inesss.qc.ca
Copyright: Gouvernement du Québec
This is a bibliographic record of a published health technology assessment from a member of INAHTA or other HTA producer. No evaluation of the quality of this assessment has been made for the HTA database.