Ontario’s Alternate Level of Care (ALC) Problem is Killing Acute Care Hospitals: Time to cut the Gordian knot.

| 27 July 2016

We need a bold solution to a major health care problem: Almost 20% of the acute care beds in Kingston are unavailable for admission of new patients. How can this be? How could 20% of the beds in the SELHIN’s only tertiary care hospital have gone missing? Why have I not heard about it? Why is this not in the newspapers? What happened to these beds? Are they closed because of construction? Is there an epidemic? Has hospital funding been cut? The answer in each case is, “No”. In fact, these 93 beds exist; however they are occupied with a growing cohort of people who everyone agrees should not be in hospital-patients requiring an alternate level of care (ALC). Thinking of bold solutions the story of the Gordian knot comes to mind.

Cutting the Gordian Knot

In mythology, the Gordian knot was used to tie an ox cart to a post in Gordium, a city located in the kingdom of Phyrygia, located in Anatolia (now in Turkey). It was Midas, son of the King who created this intricate knot. The knot had no exposed ends and, although many tried, it could not be unraveled. However, in 333BC Alexander the Great came to town. When he found no ends to the knot, he sliced it in half with a stroke of his sword, producing the required ends (a bold solution to an intractable problem). Likewise, we need a bold solution to deal with a misuse of our acute care hospitals. A solution for the ALC crisis will require us to rise above sensitivities and superficial rhetoric. Any such solution must acknowledge both the unique role and the limited capacity of our acute care hospitals. Moreover, a solution will require recognition of the specialized role of certain academic hospitals, like KGH, that are uniquely research- and education-oriented. These hospitals are represented by the council of academic hospital organizations, CAHO. CAHO represents Ontario’s 24 research hospitals that play a unique and vital role in the province’s health care system. These hospitals (if allowed to serve their role) provide advanced patient care services, train the next generation of health care professionals, and conduct leading-edge research to discover tomorrow’s care today. They are key to creating a healthier, wealthier, smarter Ontario.

Let me provide some background for you. Kingston General Hospital (circa 1835) is Canada’s oldest public hospital and is the tertiary care hospital for the SELHIN, serving a population of ~600,000. KGH has ~440 beds. As of mid July 2016 93 of these beds are occupied by ALC patients. As an example of how slow ALC patient discharge is, none of the patients on IMU H has left KGH since April. They have not been discharged either because no long term care (LTC) facility will accept them or because they have not found the LTC of their choice.

Although ALC patients are as important as any others they do not (by definition) require the services of an acute care hospital. The Ministry of Health and Longterm Care (MOHLTC), which pays for health care in Ontario, defines a patient as requiring an alternative level of care when they no longer require the services of an acute care setting. They mandate that: “When a patient is occupying a bed in a hospital and does not require the intensity of resources/services provided in this care setting the patient must be designated ALC …by the physician or his/her delegate.” Although it is the patient’s care needs that mandates the ALC, the patients themselves are often referred to as ALC patients. Once designated “ALC”, patients are supposed to be cared for at home (with/without services/programs) or in Rehabilitation centers, complex continuing care facilities, transitional care beds, long term care homes, group homes, convalescent care beds, palliative care beds, retirement homes, shelters or other supportive housing. It is generally accepted by all that ALC care should not be provided in acute care hospitals like KGH. The loss of beds that results from housing ALC patients is the major cause for congested Emergency Departments, crowded wards, and delayed/cancelled procedures and surgeries.

ALC patients and their families often may feel the system is letting them down and pressuring them to leave; conversely physicians and hospitals recognize that the ALC patient occupies a scarce, expensive and high-managed acute care bed that is intended for a very different purpose. Because ALC patients are often trapped for months to years in hospital, a single ALC admission effectively prevents dozens of acute admissions.

To understand the patient perspective let’s consider a recent well-publicized case. In a June 2013 Toronto Star story by reporter Theresa Boyle, Howard Cohen, tells the story of the challenges in finding a suitable placement for his elderly mother. The case is made by the son that the hospital misled or pressured the family, implying that a choice for LTC had to be made between only 5 institutions and had to be done quickly. Mr. Cohen, “…was stunned to discover, he says, that he had been misinformed and given inadequate information about how to select a home by a hospital social worker and a case manager from one of the province’s 14 community-care access centres (CCACs), which control entry into LTC homes.”

Long Term Health Care- A look inside the often baffling system

The article comments that hospitals have threatened patients with daily bed fees to try and encourage them to move on to a LTC facility, even if it is not the one they prefer. How did this case end? 1.5 years after the acute admission the patient was still in hospital!

Since the article was written in 2013 things have gotten worse. The numbers of ALC patients in Ontario is increasing and their length of stay (LOS) in hospital is sky rocketing, with many spending more than a year in hospital (that costs $400,000). A colleague of mine is currently caring for a patient who has been resident in KGH since 2014! The patient is awaiting placement in a long-term care (LTC) facility of their preference and will not leave. They are not being charged for their stay at KGH, so why would they leave? To illustrate the opportunity cost of devoting a bed to ALC for a 2 years consider that the average length of stay for an inpatient on the Medicine service at KGH is ~6 days. In the two years that this ALC patient has been at KGH that bed could have supported the care of 120 other patients!

The ALC debate is not about the intrinsic value of this patient’s life and their right to make health care choices; rather it is about balancing this patient’s rights against the equal rights of the 120 patients whose care was delayed or denied. It is also about the fact that ALC can be provided in many venues; in contrast tertiary care (treatment for strokes, heart attacks, heart surgery, joint replacement, ICU care) can only be provided in Ontario’s tertiary care hospitals. Sadly, when it comes to acute care it is a zero sum game and more ALC care in acute care hospitals directly translates into less tertiary care provided. Since ALC patients stay in hospital so long housing large populations of such patients fragments the hospitals inpatient teams (making rounding by physicians very inefficient) and causes Emergency Room congestion. This is not opinion….this is fact. Canadian Institute for Health Information (CIHI) in 2009 noted that ALC patients accounted for 14% of hospital days in acute care hospitals and that 43% of ALC patients were discharged to a long-term care (LTC) facility.

Things have gotten much worse since 2009. The following publically available data from the SELHIN shows how many ALC patients we cared for in acute care settings in 2014-15, Note that at KGH we discharged 72 patients (average length of stay, LOS, 113 days) and had 41 patients still in hospital with a mean LOS of 127 days. LHIN-wide we had over 300 ALC patients discharged and 140+ remained in hospital in 2014-15. That’s the equivalent of devoting one large hospital doing no acute care-just ALC care!

ALC Volumes Across SE LHIN

Sad to say, things have worsened even since last year. As of July 2016 there are 92 ALC patients at KGH! This accounts for 20% of our total number of beds. It is not that the hospital, nurses and doctors and the entire team are not trying. Indeed, while ALC populations and ALC LOS have mushroomed, the LOS for all other patients has shrunk to below the provincial average and is now ~5 days. This improvement in LOS has occurred despite a dramatic rise in admission numbers. For example on the Medicine service at KGH our admissions have increased from ~3000/year in 2012 to over 5000/year in 2015.

MOHLTC policy gives patients choice in selecting their destinations. Since occupancy in our acute care hospitals is usually “free”, patients and families can make this choice to stay at no expense. The CCAC, which governs access to nursing homes, offers the following guidelines for patients:

The Community Care Access Centre (CCAC) manages waiting lists for all nursing homes in their region. Individuals with the highest health care needs and those in hospital are given first priority to a nursing home bed. If the homes that you choose have a waiting list, you will be asked to order them according to your first and last choice (you are allowed to choose 5 homes to place on your list). Should a bed become available, but it is not on your preferred list, you can decline the bed offer and maintain your position on the waiting list of the home of your choice. However, if you reject a bed offer from a home on your list, you will be removed from all waiting lists and you will be forced to wait 6 months to reapply for nursing home placement. If your health situation significantly changes within this time period, you are allowed to reapply. Once you are offered a bed, you have 24 hours to accept the offer, and you can usually move in the next day.

Patients may choose to stay in a convenient and safe acute care hospital rather than moving to a less desirable LTC. This choice may relate to financial disincentives (pay for LTC vs free stay in hospital), the relative scarcity of LTC facilities (especially desirable facilities) and geography (proximity to the family). The MOHLTC and CCAC do not mandate that the patient and their family pay for declining placement in the first available LTC facility (and in many cases families decline all offered LTC choices). Giving the patient who is in hospital the only choice in this situation has societal consequences.

Choosing to stay in an acute care hospital when one should be in a long-term care facility, or at home, may be easier for the patient and their family but it doesn’t make sense for the system (and ultimately pits the rights of the ALC patient in an acute care hospital against the rights of others trying to access these congested facilities). According to CCAC it costs an average of $1100/day for a patient to stay in an acute care bed. Even chronic care beds are expensive (see table below).

Average Per Diem Cost

The MOHLTC and CCAC are well aware of the cost of an acute care bed, which is why the goal of their Home First policy is to return patients to their home and provide them with the necessary home care support. If an ALC patient can make it home CCAC reports that 92% of such patients were satisfied with their care in 2013-14. However, with smaller nuclear families, poverty and increasingly complex illnesses in a rapidly expanding geriatric population, home is not always a feasible destination.

It is not just the cost that is relevant to our choice of how to handle ALC. The fact is that hospital beds in Ontario are a scarce resource. In 2013 Ontario had the lowest number of beds/capita in Canada (2.4 hospital beds for every 1,000 residents). This is also low by international standards. This may be acceptable; however, only if we can properly manage this resource.

LTC facilities are themselves struggling to handle more complex residents. According to a recent report from Health Quality Ontario “The most frequent challenge cited by homes was managing the increasing acuity and complexity of residents (53% of homes), with many homes identifying challenges in managing aggression and other behaviours (26% of homes).” The table below shows the current status of our LTC facilities in the SELHIN…almost 1300 people waiting for LTC care.

Waiting for LTC placement in the SELHIN

Waiting for LTC placement

The circular problem of ALC patient disposition and choice and hospital gridlock is a tough knot to undo. Despite congestion of hospitals, individuals believe they have the right to choose the long-term care (LTC) facility they desire. In an era where the Patient’s First philosophy is promoted by the MOHLTC its hard to argue against choice. However, all choices have consequences. Allowing ALC patients to remain in acute care hospitals and failing to spend public funds to build adequate numbers of competently run LTC facilities has adverse consequences in an aging society with a burgeoning population of elderly people afflicted with complex illnesses. Those consequences include congested Emergency Departments with long wait times before admission, delayed procedures and delayed/cancelled interventions and surgeries.

Andre Picard touched on the issue of choice in a recent Globe and Mail editorial entitled “Taking patient-centred health care from rhetoric to reality” noting essentially that patient-centred care does not and cannot mean simply giving the patient everything they want. “Shared decision-making is more than about agreeing to disagree: It’s a lot dirtier and messier than that. It’s about finding a compromise that respects medical responsibility and patient autonomy.”

The proliferation of ALC patients who are trapped in acute care hospitals threatens to destabilize our ability to provide the timely acute care medicine the public expects. This blog is a call for courageous decisions to cut the Gordian knot and restore access to our acute care beds and allow Ontarians to benefit from modern advances in health care. To move forward we will have to make tough choices and speak clearly, though civilly. We need to recognize a concession to an ALC patient who refuses access to a LTC bed means an imposition on someone else-the patient who is not yet under care! Ontario’s acute care hospitals are increasingly becoming log-jammed with patients destined for LTC facilities but who are either empowered by the Province to stay put and exercise their choice or trapped by the lack of LTC facilities appropriate to their situation and convenient to their family. If the knot remains tied, everyone suffers. ERs will remain congested, procedures will be delayed or cancelled, and wards will remain choc a bloc with patients. This all occurs despite decreasing length of stay and rising health care costs. It is time to cut the Gordian Knot and allow out acute care hospitals to function.

How do we cut the Gordian knot?

Better manage LTC facilities to ensure they retain residents and do not refuse to repatriate them from acute care hospitals. There is increasingly a problem with these facilities. When patients, out of confusion or mental illness, are verbally or physically disruptive they are promptly exported to acute care hospitals where they often languish (for days) in Emergency Rooms. The LTCs then want assurance that the patient is “cured” and are slow to repatriate them. In many cases, such as dementia, the behaviors are not curable; however they can be managed and should be managed in an LTC, not an acute care hospital.
Properly staff retirement homes and other LTC facilities to deal with the types of patients who they must serve. These facilities, many of which are profit oriented, are relatively understaffed or staffed with people who lack the expertise to deal with chronically ill patients. Case management is especially challenging in the case of patients with dementia.
Build more LTC facilities. The demographics are clear. We are getting older. Society needs more high quality, subsidized retirement homes and other LTC facilities so patients can get graded support as their health care needs increase without relying on our small and expensive acute care hospital system
Designate hospitals to ensure that academic hospitals, which lead medical education, research and perform tertiary care are not receiving or maintaining significant ALC patients. The SELHIN is in the process of envisioning Health Care Tomorrow. Part of this process will hopefully be a differentiation of our 7 hospitals and some acknowledgement that while all serve patients they each have different roles. Since there will always be some ALC patients in acute settings, in the course of their journey home to LTC facilities, perhaps we need to decide at which centres these patients should reside. Failure to designate hospitals by function means that the few sites we have for Critical Care, advanced surgery, pediatrics and Ob-Gyn and advanced intervention (as well as medical research and education) become congested and dysfunctional.
Limit the time allowed for patients to await the placement of choice and limit their degree of choice. Once a patient in acute care facilities has been offered a reasonable LTC placement solution they should either be obligated to accept it or the hospital should levy a cost recovery fee to recoup the actual cost of holding that bed. Otherwise the unacknowledged subsidy makes it cheaper to stay in an acute care hospital than to move to the retirement home. If asking for payment for using our publically-funded, acute care beds for hoteling purposes sounds harsh, ask the person awaiting admission to have their hip replaced or their atrial fibrillation ablated or the patient awaiting admission to the wards who is writhing on an uncomfortable ER stretcher. Patient centered care does not mean we are freed from making the tough management decisions about the optimal use of the scarce resources entrusted to us by the MOHLTC.

I welcome your feedback.