Canadian hospitals face increasing demands on their resources. These demands include the pressures of growing and aging populations and the failure of payers in publicly funded systems to increase capacity. However, a substantial portion of current demand comes from patients whose needs could be better addressed in other settings, usually at lower costs. These patients, labelled in Canada as Alternate Level of Care (ALC), are “people who occupy an acute care hospital bed and who can be cared for elsewhere [1, 2].” In 2007-8, 5% of Canadian beds and 14% of hospital days were occupied by ALC patients with a provincial range of 2–7% . More recent studies have found higher ALC rates. One Canadian hospital had 33% of its beds occupied by ALC patients with a mean length of stay of 379.6 days. Eighty-six percent of these patients were waiting for long-term care community beds and the majority of patients declined functionally while in hospital . For high-cost users, one hospital found a significant fraction of inpatient spending on ALC days . ALC patients occupying hospital beds are a contributor to hospital crowding and inappropriate use of limited acute beds. Eliminating “hallway medicine” is a healthcare priority in Ontario, Canada  and a concern in many other jurisdictions, including Spain , Finland , the United Kingdom , and elsewhere. Identifying cost-effective solutions that reduce current ALC levels would address a critical strategic issue facing healthcare decision makers in many healthcare systems. In this paper, we outline the complexity of the ALC issue and use a case study of care redesign in one setting, Sunnybrook Health Science Centre, in Toronto, Canada, to illustrate how this issue can be addressed.
Strategies For Appropriate Placement Of Alc Patients
Risk factors for ALC include neuro-cognitive impairment, such as stroke, dementia, psychiatric illness or delirium [1, 2, 8, 9], social support needs, informal caregiver needs , lack of spouse and/or children  and homelessness . The majority of ALC patients begin their hospitalization through the emergency department . Once admitted, the inability of hospitals to expeditiously transition ALC at-risk patients back to the community worsens their functional status to the point that for many patients the only possible discharge destination is ALC  and often requires transfer to another institutional setting. The lack of appropriate social and physical hospital services is felt to contribute to the hospitalized ALC patients’ physical and mental decline . Thus, dealing with the ALC challenge has important implications for patients and families as well as the healthcare system.
Strategies to reduce ALC days include initiatives to prevent hospitalization, including community falls prevention programs, emergency department geriatric screening for ALC risk
[8, 12, 14], discharge capability with community supports, provision of hospital care in long term care facilities , community dementia screening and early management  and “assertive outreach through community mental health programs” for the homeless . If hospitalized, these individuals require multidisciplinary interventions for functional decline prevention  and promotion of early discharge to home with supports , restorative or transitional care units [16, 17] or respite care for the homeless .
State of Alternate Level of Care (ALC) at Sunnybrook Health Sciences Center
Examples of preferable discharge destinations for alternate level of care (ALC) patients include home care, palliation, convalescent care, complex continuing care, supervised assisted living, mental health, long-term Care (LTC) or rehabilitation. Sunnybrook Health Sciences Center (Sunnybrook) in Toronto, Ontario is a large academic health centre with three sites: Bayview (which provides acute care, including acute Mental Health and an Emergency Department), along with two smaller sites, Holland Center and St John’s Rehabilitation. The Bayview site is for acute hospital care with 320 beds available for emergency department admissions. The Holland Center is dedicated for acute musculoskeletal care but was able to re-purpose 28 beds for patients with prolonged waits for LTC. St John’s Rehabilitation is a 154-bed facility that focuses on burn, trauma, organ transplant and general rehabilitation patients.
During the time of this study (January 9, 2018 to February 14, 2019), there were 2847 Bayview-Holland patients who were classified as ALC. Forty-seven percent of these ALC patients were waiting greater than 3 days. In St John’s Rehabilitation, there were 96 ALC patients waiting for LTC or home care. At Bayview, the average percentage of acute hospital beds occupied by patients waiting for ALC was 17%. At Holland, the average ALC occupancy was 118%. The top three reasons why Bayview-Holland patients were classified as ALC included waits for rehabilitation (63%), palliative care (13%) and home care (9%).
Implementation Of Pine Villa:
Delayed hospital discharges and inappropriate placement of patients in acute care have been studied in a number of countries . At a system level there are a number of possible solutions, including regional coordination, monitoring and care pathways that have been used to address this issue  (Hiltunen, et al., 2020). However, local solutions are also possible.
In September 2017, in an effort to alleviate hospital occupancy pressures, a joint proposal between Sunnybrook Health Sciences Centre, SPRINT Senior Care, and LOFT Community Services was submitted to the Toronto Central Local Health Integration Network (TC LHIN), to open a transitional care home on the site of a former retirement home. Sunnybrook would serve as the operational lead for the facility, and SPRINT Senior Care and LOFT would be the service providers to support up to 68 clients (designated ALC and meeting eligibility requirements) until they could transition to their home or other discharge destination. Pine Villa is an integrated partnership model where the three partners oversee governance and quality together. With financial support from the TC LHIN (under Ontario Ministry of Health and Long-Term Care (MOHLTC)), Sunnybrook leased the Pine Villa facility, and undertook significant renovations to ensure accessibility. The facility opened its doors to ALC patients from all Toronto hospitals in March 2018.
Pine Villa is a supportive transitional care site (reintegration unit) providing short-term services for older adults and seniors who no longer require care in a hospital, and who are waiting to move home with community supports or are awaiting placement in a long-term care facility or another care setting. In Pine Villa, specialized supports are provided for patients with dementia, mental health, addictions, social determinants of health needs and responsive behaviours. Therapeutic recreation is the primary model of care that supports clients through rehabilitation allowing them to regain or maintain their current level of functioning until they are able to safely transition to their discharge destination. Admission criteria for Pine Villa requires that patients be medically stable and are able to be discharged within 3 months.
The goals in funding and staffing Pine Villa were to improve patient flow through the healthcare system, provide more appropriate settings for ALC-patients and reduce costs of care. This paper’s primary objective was to determine the potential direct ALC waiting-costs averted and the impact on patient flow-through for Sunnybrook by Pine Villa if transfers occurred on the day of ALC-readiness. This information is useful in assessing the feasibility of reactivation unit. The secondary objective was to compare Pine Villa patients’ actual discharge destination to what was originally planned at time of admission. This information is useful in further program refinements to the processes of assessing patients for transfer provide baseline information for future quality improvement initiatives.