Alternate Level of Care (ALC)
When inpatients no longer need the intensity of care or level of service provided by their admitting acute care facility, it is important to change their "patient status" to "Alternate Level of Care". The ALC designation effectively "stops the clock" measuring a patient's actual length of stay (LOS). This ensures that facility LOS measures reflect provision of acute care services and not days awaiting transfer to a more appropriate facility.
There are many reasons why a patient's movement to a more appropriate level of care may be delayed or blocked, including:
awaiting bed availability in a more appropriate facility, such as those providing dementia supportive living, long-term care, mental health services or rehabilitation; or
awaiting community services, such as specific home care interventions or home oxygen, to be readied for a return to a home, group home or assisted living facility.
Recognizing when medical management has finished and initiating an ALC patient status is among meaningful use norms expected of prescribers.
Recognizing ALC Eligibility
Any patient can be deemed ALC if “occupying a bed in a facility and does not require the intensity of resources/services provided in that care setting.” The discharge or transfer destination need not be known at the time of ALC designation. The patient must be designated ALC by the most appropriate care team member, which may be a physician, long-term care assessor, patient care manager, discharge planner or other care team member. The decision to assign ALC status is a clinical responsibility.
Determining when an inpatient has completed all interventions appropriate for the current admitting facility can involve a number of considerations. All major medical interventions should be complete, the admitting problem should be resolved or stabilized and co-morbidities should have returned to baseline status (or a new baseline). A clear discharge plan should be documented. Multidisciplinary discharge planning rounds ("Rapid Rounds" in most acute care facilities) facilitate ALC deliberations and decisions.
ALC Implications
ALC patients can have their assessments and vital signs decreased to as little as weekly while remaining compliant with standard operating procedures and Connect Care minimum use norms. Routine (repeating) laboratory tests should be minimized. Patient orders should be simplified to match the type and frequency of interventions anticipated at the intended discharge destination.
A key implication of ALC status is that it sets a virtual discharge date for the patient for use in calculations of the acute care length of stay.
Managing ALC Status
Once a decision is made to change a patient from acute care to ALC status, a prescriber, transition coordinator or nurse manager can enter an order to initiate ALC. Thereafter, Nursing usually updates the patient's ALC status as details become available about discharge destinations.
Initiating Alternate Level of Care (ALC) status
Using the "Orders" activity in a patient chart opened in Hyperspace to an inpatient encounter, enter a "Initiate ALC" order, using the "ALC - TBD" speed button.
It is important that prescribers ONLY select "ALC - TBD" and not Z-codes. Transition coordinators and/or nursing staff take care of more detailed (Z-code) ALC statuses. Selecting Z-codes too early can trigger direct charges to the patient.
Discontinuing Alternate Level of Care (ALC), reverting to Acute Level of Care status
Using the "Orders" activity in a patient chart opened in Hyperspace to an inpatient encounter, enter a "Discontinue ALC" order, typically selecting the "Acute" speed button. The "Level of Care" pick-list makes other statuses available for selection.
Quick-access to ALC orders
It is also possible to review the Level of Care for a patient directly from inpatient lists. Use or add the "Level of Care [34010802 ]" list column (see Patient Lists) to a patient list (or copy "++ AHD IP RAPID ROUNDS CORE TEMPLATE" template which contains this block). Double-clicking on the Level of Care column for a patient list row will activate a pop-up report with information about current level of care status, all prior changes and assessments done by transition planning staff. There are links to ALC definitions as well as a link that will open the chart to an orders activity so that an "Initate ALC" or "Patient Status" order can be entered. This is most useful when making adjustments during Rapid Rounds or other transition planning activities.
Finally, wherever the Level of Care appears as text (dark blue font) in an inpatient chart Sidebar, the text can be selected to activate the pop-up ALC report.