Abstract
Background: Since spring 2023, patients in “Alternate Level of Care” (ALC) have become a ministerial priority in Quebec. The ALC designation is used in hospitals to describe patients who occupy a bed but do not require anymore the intensity of services provided in that care setting. Case management committees have been established to identify these patients and reduce their waiting time in the hospital, favoring better orientation (such as return home, entry into a long-term care facility, etc.) and better collaboration between departments.
Approach: As part of a comparative project between France and Quebec, we have been documenting these case management committees by observing their meetings since September 2023 (n=43 meetings, totaling 16 hours of observation), as well as conducting individual interviews (n=6). Additionally, we analyze clinical-administrative databases on emergency admissions, hospitalizations, and ALC episodes in a hospital to better understand the profile of people who become ALC and to gain insights into their pathways and the disruptions within them.
Results: Our analyses reveal several types of vulnerabilities leading to ALC episodes, notably patients who were homeless before entering the hospital, individuals with no relatives or network to rely on (particularly associated with cognitive decline), population aging (especially linked to mental health issues, comorbidity), and an increase in the number of operations at later ages. We were also struck by unusual pathways: the recurrence of ALC episodes among certain individuals in significant numbers over the past few years and evidence of “institutional dropping,” where someone loses their place in a long-term care institution (their home) during hospitalization. These leads raise questions about the mechanisms underlying these ALC episodes, particularly in terms of responsibility and leadership: who (and how) benefits from these extended stays?
Implications: The occurrence of an ALC episode creates a blockage in hospitals and a “disruption” in the user’s care and life pathway, which could likely be prevented through improved primary care upstream of hospitalization. Our analyses will continue to model the pathways of affected individuals and identify critical points of disruption.