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Helping Residents Recover at Home: ALC Rates Reduced by 75 Per Cent

Joseph Brant Hospital Acute Care team and Ontario Health atHome team.​


By: Leslie Motz, Executive Vice President, Clinical and Chief Nursing Executive and Liz Pawlowski, Director, Medicine, Post Acute, Access and Flow, Joseph Brant Hospital, Burlington, Ontario

Over the past three years, Joseph Brant Hospital (JBH) has reduced its alternate level of care (ALC) rate by almost 75 per cent by enhancing collaboration with community partners and standardizing processes to streamline discharge planning.

JBH is committed to ensuring patients receive access to timely, high-quality care.  The impact of the pandemic on wait lists and growing emergency department (ED) visits reinforced the hospital's need to look beyond traditional ways of managing occupancy and length of stay, and minimize the number of patients designated as ALC where avoidable in the acute care setting.

“When an elderly patient is in hospital for an extended period, it can lead to complications like functional decline, delirium, incontinence, falls and infections," said Liz Pawlowski, Director, Medicine, Post Acute, Access and Flow. “While care teams do everything they can to minimize these complications, it's important to consider the benefits of a familiar setting, independence and social connection on a patient's physical and mental health."

“When a patient no longer requires acute care, the hospital is not the best place for them to be," said Leslie Motz, Executive Vice President, Clinical and Chief Nursing Executive. “A safe and effective transition from hospital to home, with supports in place based on the patient's individual needs, is critical to their recovery and allows for longer-term decision making, when the medical crisis is over, to be made from home."

Education and Collaboration

JBH leaders focused on educating staff and physicians on the Home First philosophy and providing them with the resources to successfully put it into action. JBH and Ontario Health atHome then developed several key standardized processes to support care teams in their roles and to ensure consistent, supportive discharge messaging by all care providers. These included:

  • Structuring collaborative planning rounds with Ontario Health atHome, specific to discharge planning, for acute care units
  • Scheduling patient discharge meetings within 24-48 hours of admission and providing the care team with standardized scripts to support an emphasis on Home First
  • Screening patients admitted through the Emergency Department within 24-48 hours of admission using the Blaylock Discharge Planning Risk Assessment Tool, which  generates automatic early referrals to Ontario Health atHome, geriatric clinical nurse specialists, and discharge planners dependent on risk score
  • Implementing an executive clinical leader approval process for all patients identified as high risk for ALC designation to validate that all options have been exhausted and identify any system challenges or trends
  • Standardizing patient and family education on the Home First philosophy

The hospital also strengthened its working relationships with partners in the surrounding community. This included:

  • Optimizing access to Community Paramedicine, Wellness Hubs, Integrated Comprehensive Care Program and Adult Day Programs in the community
  • Adopting the Alzheimer Society Dementia, Resource, Education, Advocacy, Mentorship (DREAM) program in JBH's ED
  • Collaborating with partners from the Burlington Ontario Health Team and Thrive Group in the implementation of the Let's Go Home (LEGHO) program to support hospital discharge and stabilization in the community
  • Working with convalescent care, retirement homes and assisted living facilities to provide  options when home discharge is not viable

Communication and Commitment to Change

Communication with patients and families is critical to the success of a discharge. While conversations about discharge planning can be challenging, especially when there has been an illness, it is imperative that conversations start early to help patients and families understand the benefits of Home First while supporting a smooth transition home.

“Ontario Health atHome is committed to delivering the right care, at the right time, in the right place, which is essential in supporting patients in their transition from hospital to home," said Amanda Westwood-Smith, Director, Patient Care Services, Ontario Health atHome.

Improving patient flow through improving ALC rates has been central to JBH's Strategic Plan, annual objectives and Quality Improvement Plan, and will remain a key focus driving the hospital's work forward.  

“We have realized some impressive outcomes with our implementation to date. We will remain focused on what is next, as well as implementing sustainability strategies," said Motz. “This work will require ongoing rigour and oversight to ensure we embed it in every corner of our organization. I am proud and grateful for the incredible successes our JBH and Ontario Health atHome teams have achieved."

“Delivering quality patient care remains at the heart of everything we do," said Pawlowski. “While we have seen success through standardized process and community partnerships, we remain committed to enhancing these strong partnerships, creating new connections and ensuring the voices of our patients and families are heard."

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