Alternate Level of Care (ALC) designations are a persistent challenge in Ontario hospitals.

Patients are designated as ALC when they no longer require acute care but cannot obtain the medical, psychological, or emotional supports they need elsewhere in their community, whether at home or in another care facility.

Having heard of our work designing complex community and stakeholder engagement processes for a range of Ontario health care providers, the ESC LHIN approached MASS LBP to design and implement a two-phase project to better understand the circumstances and decisions that lead patients to remain in hospital under ALC designation.

The ESC LHIN partnered with local health care providers throughout the region to conduct conversations and workshops with patients, family members, caregivers, and frontline staff to gain insights into the ALC pressures in Windsor/Essex, Chatham-Kent and Sarnia/Lambton respectively. This system-wide approach helped to determine how the ESC LHIN, along with its partners and patients, could work together to resolve this complex issue.

Specifically, we set out to:

• Better understand the perceptions, assumptions and decisions that result in patients choosing to remain in hospital, and identify the barriers to effective patient transitions from an acute to home or a long-term care setting
• Learn what patients and their loved ones understand about patient conditions and care needs, and the risks of prolonged hospital stays
• Generate a comprehensive picture of the education and decision-making process that patients and their loved ones go through when selecting a long-term care home

Process
For the first phase of the project, MASS launched a research and engagement process with the Erie St. Clair LHIN and their partners – Leamington District Memorial Hospital, Hôtel-Dieu Grace Hospital, Windsor Regional Hospital, and the Erie St. Clair Community Care Access Centre (CCAC) – to better understand the medical, organizational and personal circumstances that lead ALC patients to stay in hospital.

Starting in August 2011, ESC LHIN staff conducted private interviews with ALC patients and their family members. They also hosted five workshops with frontline staff to discuss their first-hand understanding and perceptions of ALC patients and their families.

Following the success of the first phase of the project, the ESC LHIN again commissioned MASS LBP to design and coordinate another series of consultations to extend the investigation to Bluewater Health, the Chatham-Kent Health Alliance, and the Erie St. Clair CCAC. Between November 2011 and January 10, 2012, ESC LHIN staff conducted additional one-on-one interviews with patients and family members, and hosted three more staff workshops.

For consistency and comparability, the programs and methodology were unchanged. In both phases of the project, MASS designed two interview manuals and trained ESC LHIN staff to host conversations with family members and patients at bedsides and in private rooms. The patients interviewed formed a profile of a challenging patient population, ranging ifrom thirty-five to ninety years old and most with complex chronic health issues. The average interview lasted forty-five minutes, allowing ample time for the patients and families to ask questions and provide thoughtful and honest feedback.

MASS also supplied the program, workshop toolkits, and facilitator training for the engagement sessions at each of the partnering organizations. Frontline staff met in small groups for two-hours, and participated in a series discussions led by LHIN staff members. The results were collected on feedback templates, which were submitted to MASS LBP for synthesis and analysis.

Outcomes
The two final reports are based directly on the input received from ALC patients, their family members, and front-line staff. These findings were presented to the region's service providers including hospitals, long-term care facilities and community care organizations, and informed the LHIN's Home First strategy. Each report includes a population profile of the patients, family members and frontline staff that explains who they are, collectively, their lived-experiences within the health care system, and their values and priorities. Each report also includes observations about the regional health system overall, and a series of recommendations to:

• Clarify the roles and responsibilities of health care providers and streamline the referral process
• Increase collaboration and communication among regional providers and patients to manage expectations and ensure consistency of care
• Enhance decision-making supports and evaluation tools for long-term care
• Review in-hospital treatment of ALC patients with particular attention to special needs cases
• Promote education to build general health system literacy, and help patients to navigate the system and make informed decisions when contemplating long-term care

Over the course of this process we:

1. Designed and led the first project undertaken by the ESC LHIN to talk directly to patients and family members about alternate level of care, what it is and why it matters
2. Provided meaningful opportunities for patients, family members and staff members to learn from one another and share their concerns, insights and ideas for improving ALC patient outcomes
3. Generated a complete and representative profile of the region’s clients and stakeholders based on lived experiences, perceptions, and values and priorities for long-term care
4. Demonstrated best practices for community engagement through facilitator training, education and leadership support for ESC LHIN staff
5. Produced a series of practical recommendations to relieve ALC pressures that are directly informed by the input of patients, family members, and front-line staff in Windsor/Essex, Chatham-Kent and Sarnia/Lambton
6. Influenced the LHIN's Home First strategy and shared the findings with all of the region’s service providers including hospitals, long-term care facilities and community care organizations.