Literature Collection

WHAT IS ALTERNATE LEVEL OF CARE? • Alternate level of care (ALC) is a designation used and applied by clinical staff to the portion of a patient’s hospital stay when the patient is occupying a bed in a facility (e.g., acute care; mental health; rehabilitation; and chronic, intermediate, or complex continuing care settings) but they no longer require the intensity of resources or services provided in that care setting. WHAT ARE THE CHALLENGES? • In 2022–2023, an estimated 6.2% of hospitalizations in Canada had an ALC component, with a provincial and territorial range of 1.0% to 8.3%. An estimated 17.0% of hospital days were for patients in ALC, with a provincial and territorial range of 6.8% to 26.1%. • Patients with an ALC designation may be more at risk of adverse events, hospital-acquired infections, mental and physical deterioration, and mortality. ALC bed days also contribute to higher hospital costs and system flow issues, including overcapacity, emergency department (ED) and hospital overcrowding, and prolonged wait times. • Patients of any age and any health condition may remain in hospital after their acute care needs have been met; however, the most common group of patients who are in ALC are older adults. • Determining whether a patient’s stay receives an ALC designation requires the application of the ALC definition while considering the individual patient’s context. There are many factors that influence whether a hospital stay will result in an ALC designation, including variations in patients, settings, and circumstances. • The ALC indicator was originally meant to capture unmet needs of patients. It is now predominantly a designation placed on a portion of patients’ hospital stays, and often patients are unaware of their ALC status and what it means. • The variation in ALC definitions and their application, as well as situational contexts such as the demographics of patients, ALC rates, and interventions, make it difficult to compare ALC between jurisdictions. WHAT DID WE DO? • To inform policy and decision-making in support of evidence-informed strategies to reduce the time people spend in ALC, we assess: o.. ALC definitions in Canada and how they are applied across jurisdictions; o.. reasons for ALC designation, including the reasons people with unmet needs receive ALC designation and remain in ALC in acute inpatient care settings and the relevant, related ethical considerations; o.. effectiveness and harms of published interventions to alleviate the ALC burden; o.. other interventions implemented in Canada and internationally that exist to help alleviate the ALC burden; o.. economic and resource considerations associated with ALC interventions to health systems and patients; o.. implementation considerations to identify facilitators of, and barriers to, implementation of ALC interventions. • Interventions were aligned with 3 categories: ALC avoidance (upstream), ALC patient flow (midstream), and ALC patient discharge (downstream). • To supplement findings from the evidence, review and to help describe the ALC landscape across Canada, we also conducted an analysis of real-world data. We developed an interactive dashboard that includes figures that describe ALC data by different provinces and territories in Canada, over time. • To support this work, we engaged people with personal and/or professional experience with ALC, caring for older adults as they age, or health care decision-making in Canada. We searched key information and data sources — including journal databases, trial registers, and websites — and conducted focused internet searches for relevant evidence on initiatives to reduce ALC. WHAT DID WE FIND? • Across the jurisdictions, ALC is defined in alignment with the Canadian Institute for Health Information (CIHI) definition as patients occupying a bed while no longer requiring the services provided by their admitting acute care facility or department as they wait for transfer to more appropriate care settings. Slight differences arise from the designation criteria and the code assignments for patients. • ALC designation involves assigning specific codes or criteria to reflect the change in a patient’s status and reasons for the designation. • ALC days are widely used as a performance indicator across jurisdictions to assess ALC, along with other metrics such as the percentage of hospitalized patients designated as ALC and the number of ALC beds occupied per day. • We found that individual sociodemographic and clinical factors, process and practice factors within and across acute and nonacute care settings, and structural factors contribute to ALC designations. We also found that multiple, intersecting factors that contribute to ALC can raise ethical considerations and present ethical dilemmas for patients, care partners, families, health care providers, and health systems in the context of ALC designations. • We examined evidence on the effectiveness of 6 multicomponent interventions that have been described in comparative studies in the published literature intended to alleviate the ALC burden in acute care hospital settings. Overall, there was very low–certainty evidence of the clinical benefits of these interventions: • The Humber River Health’s Humber’s Elderly Assess and Restore Team (HEART) program (a midstream-downstream intervention) and a step-down intermediate care unit for older patients who are hospitalized plus a 72-hour discharge target (a downstream intervention) may reduce ALC rates compared with usual care, but the evidence is very uncertain due to critical or serious risk of bias and indirectness. • The Sub-Acute Care for Frail Elderly (SAFE) Unit located in a long-term care [LTC] home in Ontario (a downstream intervention), vertical integration of care (a system-level intervention), and urgent and emergency care vanguards (a system-level intervention) may reduce ALC lengths of stay compared with usual care or no intervention, but the evidence is very uncertain due to critical risk of bias and indirectness. • Coordinated care planning based on the Health Links model (a system-level intervention) may make little to no difference on ALC lengths of stay compared to no intervention, but the evidence is very uncertain due to serious risk of bias and serious imprecision. • We also identified 11 noncomparative studies (that were not critically appraised) of the following: o.. six midstream interventions — increased step-down beds, specialized acute care space or service, and enhanced discharge planning; o.. two downstream interventions — transitional care units; o.. three system-level interventions — integrated care for older people and home-first strategies. • From the literature, we identified a total of 19 new and emerging interventions in Canada, 10 international interventions, and 2 international case studies. Interventions intended to help reduce ALC designation of patients, improve patient flow, facilitate patient discharge, and provide educational and practical guidance about ways to alleviate the ALC burden. • Findings from a survey conducted as part of our environmental scanning activities suggested that although most jurisdictions use the CIHI definition of ALC, there is variation in the type of staff who assign ALC codes, the uses of ALC data, and fees associated with ALC designation. Strategies to alleviate the ALC burden most often aim to reduce ALC length of stay, are typically set in hospitals, involve a wide range of clinical and nonclinical staff, and are frequently targeted toward older adults, people awaiting discharge to residential care, and people with complex needs. • Resource impacts should be considered with respect to the implementation of any strategies to alleviate the ALC burden, including those pertaining to set-up, management, and delivery of care, alongside careful consideration of coordination, flow between different strategies, and redistribution implications. We identified 1 Canadian economic evaluation on the cost-effectiveness of the SAFE Unit (a downstream intervention) compared with usual care to alleviate the ALC burden. The overall literature suggests that this and other strategies for alleviating ALC may be less costly, resulting in the opportunity to treat more patients at the required level of care and thus increase efficiency in the use of health care resources. • Key participants in the implementation of ALC interventions include patients, care partners, clinicians, support staff, government, administrators, and communities, suggesting everyone involved plays a role in the successful implementation of these interventions. • Care providers should consider the use of cross-sector integration, enhanced communication, and multidisciplinary collaboration, supported by high-quality data that are integrated with the flow of the patient through their health journey to inform decision-making to aid in successfully implementing of ALC interventions. • Implementation should be approached as a continuum where approaches are tailored to the needs and complexities of the individual patient while assessing the requirements to transition between each step of care. NEXT STEPS: • Our Health Technology Expert Review Panel will use the findings of this report to support deliberations that will result in the development of guidance to inform decisions around evidence-informed strategies and initiatives that could be considered to reduce the time patients spend with an ALC designation.

BACKGROUND: For a decade, experts have suggested integrating mental health care into primary care to help bridge mental health Treatment Gap. General Practitioners (GPs) are the first port-of-call for many patients with mental ill-health. In Indonesia, the WHO mhGAP is being systematically introduced to its network of 10,000 primary care clinics as an add-on mental health training for pairs of GPs and Nurses, since the end of 2015. In one of 34 provinces, there exists an integrated care model: the co-location of clinical psychologists in primary care clinics. This trial evaluates patient outcomes among those provided mental health care by GPs with those treated by clinical psychologists in primary care. METHODS: In this partially-randomised, pragmatic, two-arm cluster non-inferiority trial, 14 primary care clinics were assigned to receive the WHO mhGAP training and 14 clinics with the co-location framework were assigned to the Specialist arm. Participants (patients) were blinded to the existence of the other pathway, and outcome assessors were blinded to group assignment. All adult primary care patients who screened positive for psychiatric morbidity were eligible. GPs offered psychosocial and/or pharmacological interventions and Clinical Psychologists offered psychosocial interventions. The primary outcome was health and social functioning as measured by the HoNOS and secondary outcomes include disability measured by WHODAS 2.0, health-related quality of life measured by EQ-5D-3L, and resource use and costs evaluated from a health services perspective, at six months. RESULTS: 153 patients completed the outcome assessment following GP care alongside 141 patients following Clinical Psychologists care. Outcomes of GP care were proven to be statistically not inferior to Clinical Psychologists in reducing symptoms of social and physical impairment, reducing disability, and improving health-related quality of life at six months. Economic analyses indicate lower costs and better outcomes in the Specialist arm and suggest a 50% probability of WHO mhGAP framework being cost-effective at the Indonesian willingness to pay threshold per QALY. CONCLUSION: General Practitioners supported by nurses in primary care clinics could effectively manage mild to moderate mental health issues commonly found among primary care patients. They provide non-stigmatising mental health care within community context, helping to reduce the mental health Treatment Gap. TRIAL REGISTRATION: ClinicalTrials.gov NCT02700490.