What if… we could improve the flow of patients admitted to the hospital who no longer need the intensity of care a hospital provides?

Then… we could shorten the time patients have to wait in the emergency department.

“There are many patients who require what we call an ‘alternate level of care’ (ALC),” says Dr. Jenny Basran, an internist geriatrician with Saskatoon Health Region and clinical co-lead of the provincial Emergency Department Waits and Patient Flow Initiative.

“Patients who require an alternate level of care often remain in hospital even though they no longer require the intensity of care, or level of service, provided in a hospital,” says Dr. Basran. “These patients are not able to go home because they still require some assistance with getting their function back or getting their home situation organized. We have limited options for this type of assistance in the community, so we keep them in hospital. Not only is this not the right environment for these patients, but it can actually slow down their improvement.”

ALC patients who remain in hospital beds also create a backlog in the emergency department, as patients being admitted to the hospital have to wait longer for a bed. Dr. Basran and her team are asking: if supports in the community were available, could we help ALC patients get home sooner?

Staff consult with a patient.

Finding the solution is a three-step process, says Dr. Basran. The first is to standardize the collection of data on ALC patients who have been admitted to hospital. Currently, the data being collected is capturing only those patients who are waiting for long-term care placement and these patients account for only half of the ALC patients in hospital.

“The previous ALC data would suggest that the solution to better patient flow is to add more long-term care beds,” says Dr. Basran, “but long-term care is only one category of ALC. Other categories might include patients who need short-term assistance at home due to reduced mobility, patients with cognitive impairment or behavioural issues, or patients with an inability to manage their personal care or medications. Because we don’t have the right resources in the community, all of these issues are keeping people in the hospital and contributing to a longer length of stay in hospital.”

In January of this year, Dr. Basran participated in eHealth Saskatchewan’s Rapid Process Improvement Workshop (RPIW). The RPIW brought together health professionals, including frontline staff, data experts and health information staff, from across the province to create a standardized form to collect ALC data.

“We created the form, and it was trialed during the RPIW. Then, during the Region’s 14 Day Challenge, we asked the 7th floor medicine team to pilot the form,” says Dr. Basran. “We discovered that the challenge in collecting the data is asking people to think outside the box. When filling out the form, we want clinicians to ask, ‘If x, y, z existed, could this patient transition from the hospital to the community to complete their care?’ Right now, many of the programs we need don’t exist, so it takes a shift in mindset to think of these options and to document them.”

In addition to identifying which patients are done their active stage of care, it is also important to understand why patients require an alternate level of care.

“It’s not good enough for us to just identify who is and isn’t ALC,” Dr. Basran explains. “We also need to know the reasons patients are ALC, so that we can determine what specific community services they require. Services can then be expanded or developed to meet these needs, rather than the Region initiating a generic expansion of services in the community.”

This second step in the process assesses how well the system is doing.

“The ALC form is designed to collect information on how long it takes the system to sort out the specific needs of the patient,” says Dr. Basran. “This is where quality improvement initiatives can focus their attention to help with patient flow.”

The third step is transitioning ALC patients from the hospital to a community setting, a task that the Region’s 90 Days of Innovation: Ready Every Day Community Strategies team has started. On July 13, the team began transitioning ALC patients from hospital to Preston Park II, an assisted living facility participating in the Region’s Transitional Care Bed pilot project.

“Our goal is to put the right patient in the right place at the right time,” says Corey Miller, team lead. “The pilot is the first step to achieving this goal. It’s important for our healthcare teams to stay diligent in identifying and designating patients as ALC so that patients can be considered for community initiatives like transitional care beds.”

“The time spent gathering ALC data has been very exciting and essential in determining the needs of our patients once they no longer require an acute care setting,” says Audrey Cowie, registered nurse on 7th floor medicine at St. Paul’s Hospital. “The data is needed to determine the appropriate supports that need to be implemented in the community, providing a more conducive period of recovery and/or transition for our patients, while opening up acute beds.”

As part of the 90 Days of Innovation, the Community Strategies team created an electronic version of the ALC form that is currently reporting an average of 125 ALC patients a day. To make the data collection form even more useful, Dr. Basran says the long-term goal is to incorporate an option for clinicians to identify all of the services patients might qualify for, to place patients on wait lists and to submit referrals.

“ALC data collection is providing the foundation for the Region to reduce long wait times in the emergency department,” says Dr. Basran. “It’s allowing us to identify not only who is ALC but also why they are ALC and how the healthcare system and community can collaborate to better serve them.”

The province is aiming to have 100 per cent of ALC patients in Saskatchewan correctly identified with a single provincial form by April 2016. In addition, the Senior Home Visit initiative – a project supported by the provincial government – is being developed to directly respond to some of the needs identified by the ALC project.

In 2015, Dr. Jenny Basran received the Saskatchewan Medical Association Physician of the Year award and the Saskatchewan Alzheimer Society Honourary Lifetime Membership Award.