Alternate Care Plans and Options
The term “Alternate Level of Care” (ALC) is used in health care settings, including acute care, complex continuing care, mental health, and rehabilitation, to describe persons who occupy a bed in a facility but no longer require the intensity of resources and services provided in that setting. In the context of this analysis, ALC identifies a person who has completed the acute care phase of his or her treatment but remains in an acute care bed.
It is well documented in the literature that waiting in an acute care bed for placement may lead to a decline in the health of the individual. In such cases, facilitating a successful transition to another community setting such as supportive housing, or to residential care requires careful consideration of resource availability, costs, risks and benefits to the individual and the health system as a whole.
Clients who wait to be discharged to home care or residential care have diverse needs, strengths, and preferences. Most seniors admitted to residential care following recent discharge from acute care had ALC days. There is preliminary evidence to suggest that new initiatives, including Home First, have helped reduce the burden of ALC days by diverting potential residential care clients’ homes.
The rate of recovery from illness for the elderly is less and they are more susceptible to deconditioning. The functional decline has been identified as a leading complication of hospitalisation of older people and can manifest as the development of malnutrition, decreased functional mobility, loss of skin integrity, incontinence, falls, the development of delirium, problems with medication, poor self-care and depression. There is also evidence that functional decline in older people is associated with adverse outcomes ranging from increased length of stay to higher levels of institutionalisation and increased mortality.
In responding to the specific care issues of older people, Health Services must be aware of and apply practice based on the best evidence. Through assisted living or supportive housing, older people will experience a reduction in functional decline and adverse events while receiving care from the Health Service.
Improving Care: Principles and Processes
The principles and processes for improving the care of older people include the expectation that Health Services will have a clinical governance responsibility to provide the kind of care that reduces the risk of adverse events for older people and supports them to maintain or reach their optimal level of independent functioning.
ALC patients may be best cared for at home, with the right kind of support. Persons with complex care needs without a strong support system are more likely to have waited in acute care before home care admission, suggesting that they were waiting for a caregiver to be available. Initiatives such as Ontario’s Home First Program are helping to reduce the number of times seniors wait in the hospital. This program aims to identify individuals at risk for residential care admission to provide adequate support to enable a successful transition to home care.
The idea of Home First is to put in place adequate support across the continuum of care to enable a person’s transition to home from acute care while reducing ALC days and transfers to residential care. Through this initiative, individuals and families are supported to make decisions about future health care including residential care placement while at home, rather than in the hospital setting.
Older people often have complex care needs and may have comorbid issues that require a holistic, problem-solving approach to their care. To achieve this, older people must be risk-screened upon contact with the Health Service and, if the risk screen is positive, they receive a comprehensive assessment based on which the older person’s care plan should be built. Care planning should be person-centred and interdisciplinary in approach. An interdisciplinary approach requires that the team of healthcare professionals work together to plan for care that meets the older person’s central goals. The presence of a caregiver is often a significant factor in enabling an older person to return to or remain living in the community.
Acute care at home (Hospital in the Home – HITH) consists of providing an appropriate level of treatment for a person’s acute health care needs in the home. It aims to return a person to a state of well-being so that they no longer need treatment. HITH is a safe, acceptable and cost-effective alternative to acute in-hospital care for a wide range of clinical conditions (North Western Health, 1999). The program is responsible for identifying the person’s various needs via a comprehensive assessment and providing the full range of services the person requires. As caregivers play a significant role in assisting in the care and support of HITH patients, their needs must be also considered simultaneously.
Who is eligible for receiving home health care services?
The elder person can receive home health care if he/she is under the care of a primary health care doctor and is certified that he/she is:
- housebound because leaving home is not recommended because of a health condition or cannot be done without help, such as using a wheelchair or walker, needing special transportation, or getting help from another person.
- in need of skilled nursing care, physiotherapy and psychosocial therapy, social services: counselling for the elderly and family members, and transitional home health care after release from hospitalization.
Two disorders affect mental function differently which calls for complex care needs. Delirium impairs the ability to pay attention and think clearly. Dementia causes loss of memory and a severe decline in all aspects of mental function (Beers & Berkow, 2003). With the increasing number of older people in hospitals, more people with delirium or dementia will need appropriate care. People assessed as having complex care needs should have a single person coordinate their care by working with them and their caregivers, where possible.
Care coordination should be provided in the hospital and bridge the person’s transition back to the community.
What services can be offered in-home settings?
The types of services that may be provided as part of the home health care designed to fulfil the individual health care needs package include:
- Health education: For the elderly and family members, including nutrition, prevention of falls, healthy lifestyles, and so on.
- Personal care: Exercising, checking vital signs such as blood pressure, pulse, heart rate and blood glucose level.
- Preventive services and early detection: Prevention of bed ulcers, dressing of wounds if needed, measuring blood pressure, regular laboratory tests, and breast self-examination.
- Psychosocial support and social services: Counselling for the elderly and family members. Studies on social support conclude that it slows cognitive decline, the onset of dementia and the progression of disability, both mental and physical.
- Transitional home health care (after release from hospitalisation): To empower the elderly to become more involved in managing their chronic illnesses and more confident in communicating with healthcare professionals. Many studies have found that patients who received transitional home health care are approximately half as likely to return to the hospital as patients who do not and that this positive health outcome continues for more than six months.
- Linking the elderly and their families with other services in the community, such as supported housing community social services and volunteer-based services.