Healthcare Quarterly

Healthcare Quarterly 9(2) March 2006 : 22-24.doi:10.12927/hcq..18097

CIHI Survey: Alternatives to Acute Care?

Aleksandra Jokovic, Akerke Baibergenova, Kalyani Baldota and Kira Leeb


After treatment in acute care hospitals is completed, many patients need follow-up or ongoing health services in settings other than in an acute care facility. Those services include those provided in continuing-care institutions (such as rehabilitation centres, long-term-care facilities and nursing homes), through home-care programs and by patients' families. However, alternatives to acute care are not always readily available for patients who require them and this leads to extended stays in acute care facilities. Patients occupying acute care beds when they are well enough to be cared for elsewhere are identified as alternative level of care (ALC) patients in some hospitals.
Patients experiencing ALC hospital stays do so for a variety of reasons. In a recent survey of hospital executives from five countries, limited availability of post-acute care was identified as one of the factors leading to discharge delays from acute care facilities (Blendon et al. 2004). According to some Ontario-based reports, other reasons for ALC hospital stays include inadequate communication and coordination among care providers, lack of hospital discharge-planning protocols and deficient utilization management of post-acute services (Ontario District Health Council Archives 2002; Bruce 2002).

Here we look at the characteristics of the patients experiencing alternative level of care stays in hospital in 2004-2005.

Waiting to Leave the Acute Care Hospital

According to the Canadian Institute for Health Information's (CIHI) Discharge Abstract Database, there were almost 73,000 patients designated as ALC patients among 2.4 million patients admitted to acute care hospitals outside of Quebec between April 1, 2004 and March 31, 2005.1 This is up by 13.6% from 2003-2004 and 19.6% from 2002-2003.

Overall, at least 3% of inpatients in 2004-2005 remained in acute care beds one or more days after a physician said they were ready to move to another level of care. Although this represents only a small fraction of the inpatient population, these patients accounted for close to one tenth (8.7%) of the total inpatient days in this year, with an average length of stay five times that of the overall inpatient average length of stay (36.1 vs. 6.5 days). The proportion of the total inpatient days attributed to ALC varied significantly across the country. However, substantial differences exist in the level of ALC reporting, rendering meaningful cross-country comparisons challenging. Given the cross-Canada reporting differences, these results likely underestimate the number of patients in Canadian hospitals receiving this level of care.

Who Are ALC Patients?

In 2004-2005 the majority of patients with ALC stays were female (58.1%). An overwhelming majority (82.5%) were also 65 years of age or older (mean age 75.4 years). In urban areas,2 ALC patients were about equally likely to be from neighbourhoods in one of the five quintiles of the income distribution: 19.4%-21.2%.

More than half of all ALC patients in this year were hospitalized for the treatment of trauma, neurological, mental diseases and disorders, or cardiovascular or respiratory diseases (Figure 1). Most commonly, ALC stays occurred among patients with neurological diseases (10.6%), trauma (7.4%), HIV infections (6.7%) and mental diseases and disorders (6.1%).

Where Do They Go Upon Leaving Acute Care Hospitals?

Of those receiving alternative level of care stays in acute care facilities, nearly two in five (39%) were eventually transferred to long-term-care beds and another 10% were transferred to inpatient rehabilitation facilities (Figure 2). One in three of these patients were discharged to their home, with or without the requirement of home-care services. Another one in ten patients died during their ALC stay.

As Canada's healthcare system is constantly challenged to improve performance, a better understanding of ALC stays may help to inform processes designed to ensure high-quality care and optimize the use of scarce resources.

About the Author(s)

Aleksandra Jokovic, B.D.S, MHSc, PhD, has been with CIHI since September 2005 as Project Lead, Health Services Research. Prior to joining CIHI, she was employed for many years by the Community Dental Health Services Research Unit, University of Toronto as a Research Associate responsible for projects related to the planning, organization and delivery of public dental health services in Ontario.

Akerke Baibergenova has a medical degree from Kazakhstan, where she also practised medicine. She holds a Master of Public health degree from State University of New York (Albany). Currently she is a lead Senior Analyst at CIHI in Health Services Research.

Kalyani Baldota, MSc, BDS, is an Analyst with the Health Services Research department at CIHI. Prior to joining CIHI, she was working as a Research Associate at the Community Dental Health Services Research Unit at the University of Toronto.

Kira Leeb, MA, Manager, Health Services Research has managed the production of CIHI's annual report on the health of Canada's healthcare system and has led the production of more focused reports or research on Canada's healthcare system.


Blendon, R.J., C. Schoen, C. M. DesRoches, R. Osborn, K. Zapert and E. Raleigh. 2004. "Confronting Competing Demands to Improve Quality: A Five-Country Hospital Survey." Health Affairs 23(3): 119-135.

Bruce, S., C. DeCoster, J. Trumble-Waddell and C. Burchill. 2002. "Patients Hospitalized for Medical Conditions in Winnipeg, Canada: Appropriateness and Level of Care." Healthcare Management Forum Suppl: 53-57.

Ontario District Health Council Archives. 2002. "Local Health System Monitoring Report." Retrieved December 5, 2005. < >

Wilkins, R. 2004. "PCCF+ Version 4D User's Guide (geocodes/PCCF)." Automated Geographic Coding on the Statistics Canada Postal Code Conversion Files, Including Postal Codes to December 2003. Catalogue no. 82F0086-XDB. Ottawa: Health Analysis and Measurement Group, Statistics Canada.


1. Comparable data from Quebec were not available at the writing of this article.

2. Only urban-area postal codes were used in this analysis to minimize socioeconomic misclassification (Wilkins 2004).


Be the first to comment on this!

Note: Please enter a display name. Your email address will not be publically displayed