The number of Alternate Level of Care (ALC) patients in Ontario has steadily increased, signifying barriers that exist affecting the timely transition of patients to appropriate care settings and access to services. The volume of patients designated ALC is influenced by system capacity limitations and hospital performance. To effectively address these barriers, hospital processes must be optimized, and system challenges identified and made visible to regional authorities allowing for better alignment of community resources on a continued basis. Humber River Hospital worked in collaboration with the Central Local Health Integration Network (LHIN), Hospitals and Home and Community to prioritize areas for improvement in ALC management and avoidance, resulting in the development of the Discharge Planning Pathway and iPlan.
This practice demonstrates an innovative approach to discharge planning that combines standardized clinical workflows with a newly developed application, implemented across Central LHIN. The Discharge Planning Pathway allows for the early identification, engagement and management of patients that require discharge planning interventions, and is supported by literature and leading practices. iPlan is a new technology that integrates with hospital electronic medical records, and brings together information from partnering hospitals and the community. The flow of patients is captured in real-time providing situational awareness, improved communication between patients/families, hospital and community teams, shared accountabilities, system level data to inform decision-making and future planning, and a platform for further community engagement. Outcomes observed post implementation include a proactive discharge planning culture with timely engagement of patients and a decrease in ALC rate and days.