Alternate Level of Care (ALC)
Definition
Alternate Level of Care (ALC) is a term used by hospitals to identify patients who occupy a particular hospital bed but do not require the intensity of services provided in that care setting. Defined by the Canadian Institute for Health Information, the ALC designation figures in comparisons of acute care utilization across Canada.
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 level of care from "Acute" to ALC. The ALC designation effectively "stops the clock" measuring a patient's adjusted acute length of stay (ALOS). This ensures that length of stay 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 care setting may be delayed or blocked, including:
awaiting bed availability in a different facility, such as Continuing Care Homes (Type A or B) or facilities providing 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 supportive living facility.
Recognizing when a patient is medically ready for discharge (MRD) and initiating an ALC designation is among the meaningful use norms expected of prescribers.
Medical Readiness for Discharge and Alternate Level of Care
An inpatient is considered "medically ready for discharge" (MRD) when the primary provider discipline (referred to as "medical" for simplicity) for an inpatient encounter has completed its clinical tasks and the patient is dischargeable from a "medical" perspective. Other needs (e.g., further mobility promotion, destination facility readiness, community home care readiness) may require more time to be spent in the current hospital. Accordingly, the expected discharge date may differ from the MRD date.
Once a patient is medically ready for discharge, consideration should be given to shifting the patient's level of care to ALC. However, MRD and ALC are not the same. Patients may remain in a MRD state for some time before an ALC determination is made. The ALC status is assigned when a medically ready patient remains in hospital because they are waiting for a different setting or service (e.g., home care, rehabilitation, continuing care bed) to become available.
Prescribers are responsible for MRD decisions. Moving from medically "not-ready" to "ready" usually changes expectations for the frequency of testing, intensity of monitoring, invasiveness of therapy, and type and periodicity of clinical documentation.
The broader multidisciplinary care team has input to ALC decisions, which may be actioned (ordered) by a prescriber, nurse manager, or transition coordinator. Whereas MRD is a clinical determination, ALC is an administrative designation. An ALC designation flags that a patient occupies a hospital bed but not actually require the resources of that specific care setting. ALC designations are important to bed planning, capacity management, and resource use measures like ratios of actual to expected lengths of stay.
While MRD and ALC are not exactly synonymous, it would be unusual for an MRD patient to remain at an acute level of care for more than a few days. Likewise, it would be surprising for an ALC patient to not be medically ready for discharge.
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, transition coordinator, 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" (LOC) pick-list makes other statuses available for selection.
Quick-access to ALC order panel
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).
Hovering over the Level of Care column will activate a popup display of LOC information. This includes an alert if the current Medical Readiness for Discharge (MRD) setting does not match the current LOC status. Links facilitate rapid access to LOC orders.
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 panel so that an "Initate ALC" or "Return to Acute" order can is set up ready for signing. This is most useful when making adjustments during Rapid Rounds or other transition planning activities.
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 tools.
Finally, discharge planning "readiness ribbons" include a visual prompt to consider initiating ALC status if the patient has been found medically ready for discharge but still has an acute level of care. Clicking on this opens the quick-sign ALC order panel described above.