Improving capacity at all levels of care: A collaborative approach


When people are unable to move from acute care to a more appropriate health facility in a timely manner, the consequences are felt system-wide. Wait lists grow, emergency departments become over-crowded, and a lack of available beds result in slowed discharges and admissions.

This critical issue has become a significant challenge to the Canadian health-care system.

Recently in Ontario, all hospitals have incorporated a standardized provincial definition for this issue. “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 Alternate Level of Care (ALC) at that time by the physician or her/his delegate. The ALC wait period starts at the time of designation and ends at the time of discharge/transfer to a discharge destination… ” (Provincial ALC definition).

Many hospitals have developed innovative strategies for reducing and managing the number of ALC patients. These include introducing education programs for patients and families, establishing dedicated ALC beds, and implementing patient flow policies.

However, for a comprehensive resolution, health-care providers must continue to tackle this issue system-wide, in a collaborative and coordinated manner. Acute care, rehabilitation, complex continuing care, long-term care, mental health and other health- care providers need to work together to find practical solutions to this issue.

St. John’s Rehab Hospital is playing a critical role. Together with North York General Hospital (NYGH), the hospitals have integrated their inpatient rehabilitation services into a focused, specialized program at St. John’s Rehab.

The partnership, formed in March 2008, allowed NYGH to convert its inpatient rehabilitation program into acute care space, thereby reducing wait times in their emergency department. St. John’s Rehab Hospital used newly added resources to admit patients with additional medical needs, and increase the occupancy of available inpatient beds.

This innovative program represents one of Ontario’s first major health integration projects. It is an example of how hospitals and Local Health Integration Networks (LHINs) can collaborate to find practical solutions to the ALC challenges that affect all levels of health care, including post-acute hospitals.

According to a report by the Greater Toronto Area Rehabilitation Network, 62 per cent of referrals from rehabilitation did not receive a response within a two business-day benchmark, and 31 per cent of these referrals received responses three to ten days after the referral was sent. These statistics clearly demonstrate room for improvement in admission and discharge practices within rehabilitation and other post-acute hospitals.

To help facilitate a smoother process within our own walls, St. John’s Rehab embarked upon a pilot project in January 2009. Funded by the Central LHIN, the project expanded rehab therapy and admissions to seven days per week, and increased access to outpatient rehabilitation.

With the ability to admit and discharge patients every day of the week, St. John’s Rehab can care for 6 per cent additional inpatients each year. This frees up space at acute care hospitals, allowing more patients to get the immediate care they need, while reducing their wait times.

The pilot project quickly showed successful results: in less than a month, St. John’s Rehab eliminated its wait list for priority outpatient care, opening up space to improve the continuum of care. We also opened up weekend admissions and therapy, and reduced the wait time to be transferred from acute care to inpatient rehabilitation.

On May 19, 2009, the Central LHIN announced that it would permanently invest $4 million per year in St. John’s Rehab to continue the expanded service.

This funding will allow our interprofessional team to provide the same excellent rehabilitation care every day of the week. Patients can be admitted from our acute care partners earlier, participate in rehabilitation sooner, and return to their communities healthier.

St. John’s Rehab continues to focus on effective solutions to address the ALC issue. We have adopted LEAN thinking – a methodology that brings together teams of front-line staff to examine current processes and identify opportunities for improvement. A major goal is to determine how we can better reduce each patient’s length of stay. Within this goal, we are focusing specifically on admissions and discharge planning, and other aspects of the patient’s transition through the system.

Although the issue of ALC presents many challenges, we look forward to developing additional partnerships that ensure patients receive optimal care in the most appropriate setting. Through continued collaboration, we can find innovative solutions that meet the needs of the health care system and, most importantly, help rebuild the lives of people who require our vital level of health care.