Literature Review Hospital wait times have been a notorious problem for patients within the Ontario health

care system for many years. According to reports by the North Simcoe-Muskoka (NSM) Local Health Integration Network (LHIN), 90 percent of emergency room (ER) patients are treated within nearly eight hours, compared to the provincial target of four hours (North Simcoe Muskoka Local Health Integration Network, 2012). Delays in treatment and long wait times are associated with limited hospital resources. Within the NSM LHIN 80 percent of the total time in hospital for ER patients is spent waiting for bed availability (NSM LHIN, 2012). One of the problems impacting the availability of hospital resources is the issue of hospitalized alternative level of care (ALC) patients. ALC patients are individuals in hospital which do not require acute care, but do require continued care (Ontario Home Care Association, 2009); these individuals represent on average 20 percent of bed usage in Ontario hospitals and the NSM LHIN respectively (OHCA, 2009). Some of the barriers to discharge for ALC patients include: problems with infrastructural organization and the use of resources at the government level, the level of the various regulating bodies, and the hospitals themselves which contribute to increased ALC patient loads; misconception about the LTC homes, disconnects in communication and information within the hospitals and their regulating bodies which present delays, furthering the issue of hospitalized ALC patients; and personal issues related to the patients themselves which affect the ALC decision making process. This review will explore the areas identified as impacting ALC patient flow and any areas where further research is needed. Infrastructure and Utilization of Resources

At the level of government, several changes have taken place that have both contributed to and addressed the issue of ALC patients. In June of 2007 the Ontario government introduced the Long Term Care Homes (LTCH) Act which was designed to help improve and strengthen care for LTCH residents (Ontario Health Association, 2010). One of the provisions under the act stated that ALC patients may list up to five treatment facility options in ascending order of preference, and may choose to wait in the hospital for availability in their chosen facilities (Community Care Access Centre, 2011). In 2009, the government of Ontario issued a standardized definition of ALC in order to collect data on hospitalized ALC patients so as to improve patient flow and reduce ER wait times (OHCA, 2009). Using data captured from ALC patients in Ontario hospitals, the Community Care Access Centre (CCAC) reported that longstay patients (>40 days) account for 50 percent of the total number ALC days (CCAC, 2011). Furthering this finding, the CCAC (2011) conducted survey research aimed at characterizing the long-stay cohort of ALC patients; the findings indicated that one of the main infrastructural barriers to discharge was the LTCH Act (2007) provision allowing patients the choice to wait in hospital; another barrier was a delay in responses from LTC homes. This finding is supported by in-depth interview research conducted with various stakeholders in Ontario LTC who reported that the efficiency was compromised due to an over regulation of the LTC sector (Munro, Downie, Stonebridge, Sleiman, Stuckey, & Watt, 2011). Recommendations for resolving these issues include allowing greater lateralization of decision making among the LTC sector and other health officials (CCAC, 2011). Finally, seasonal trends have be found to depict variability in ALC concentration throughout the year (NODHC, 2004), but further research is needed to investigate the factors contributing to the seasonality of ALC patient flows. Disconnects/Communication Gaps

Among the findings reported by the CCAC (2011) study on long-stay ALC patients, several disconnects in information and clarity were identified: a lack of a consistent reassessment process at most hospitals resulted in patients being designated for inappropriate destinations; a lack of support from health care staff due to fear of unsuccessful transitioning was found to be a barrier to transition; and a systemic lack of knowledge regarding availability, resources, eligibility criteria, and suitability of options resulted in patients being designated for inappropriate destinations. Based on these findings the CCAC (2011) recommended that in November of 2011 the Toronto Central (TC) LHIN implement an intensive case management (ICM) model involving the CCAC case managers who possess knowledge of options, eligibility criteria, waiting time, and contact information. The recommendation yielded positive results: 94 percent of patients identified at the TC LHIN as being designated for the wrong destination were able to be placed in an appropriate facility. The CCAC (2011) further recommended the standardization of responses between LHINs in order to escalate communication. The findings by the CCAC (2011) regarding information and clarity were paralleled in a study conducted in Thunder Bay, Ontario which found disconnects in resource management strategies; interview and focus group data derived from various stakeholders within the health care system found there to be a lack of communication which resulted in ineffective discharge planning and the misappropriation of resources (NODHC, 2004). Some of the recommendations for addressing disconnects within the system also paralleled those by the CCAC, including an establishment of a Utilization Management Program resourced with case managers, a physician, and supported by standardized clinical criteria sets. Further research on disconnects occurring at the level of patient understanding could be useful in determining the personal factors influencing the LTC decision making process among ALC patients.

Personal Factors Hospitalized ALC patients tend to represent a specific demographic of individuals: ALC patients are generally advanced in age, with the majority of patients being over 75 years (Munro et al, 2011). There are various health and social issues specific to the aged ALC population including more functional impairments such as cognitive deficits and mental illness, as well as complex care issues such as comorbidity of disease (Costa & Hirdes, 2010; Varriccho, 2009). When compared to at-home patients using RAI-HC assessment data, ALC patients over the age of 75 were found to be more likely to have a primary caregiver who was unable to continue with at-home care which could be related to the stress of caring for someone with complex care issues and functional impairments (Costa & Hirdes, 2010; Varriccho, 2009); this is a complex issues as home has been shown to be the best place for recovery whereas hospitalization puts patients at risk of acquiring infections and other secondary illnesses, becoming depressed, and losing mobility (Varriccho 2009). Literature reveals an age based bias in treatment options based on income as older patients typically have less access to income (Kane & Kane, 2001) and LTCH costs over $50 per day in Ontario provincial standards (Munro et al, 2011). Even though research shows a high level of satisfaction in studies conducted on nursing home residents, stigmatization and fear of long term institutionalization at advanced age may deter patients and family members from making the decision to move to a LTCH (Kane & Kane, 2001). Because making such a big decision in a state of crisis increases stress, the CCAC recommends identifying factors for early intervention (CCAC, 2011). Previous research identifying age based preferences in treatment has revealed some insights into safety verses socialization needs (Kane & Kane, 2001), but more

research needs be conducted in order to better understand the patient level decision making process. Conclusion Identifying ways in which to reduce the number of hospitalized ALC patients is imperative for helping to reduce ER wait times, improve patient flow, and relieve hospital resources for acute care patients (OHCA, 2009). The standardized definition of ALC introduced in 2009 has enabled the production of accurate and readily available data regarding patient flow, an in-depth analysis of the factors relating to seasonal trends in ALC patient flow may shed light on effect of additional infrastructural issues. Innovative research conducted by the CCAC (2011) has identified several disconnects within the health care system; however further research regarding disconnects that may be occurring at the level of the patient could shed light on issues pertaining to the decision making process. Finally, an age specific demographic presents information on many health and social variables that contribute to hospitalization of ALC patients, such as late intervention (CCAC, 2011) and complex care issues producing family fatigue (Costa & Hirdes, 2010), but further research investigating the internal factors influencing the patient and family members decision to remain hospitalized is needed in order to determine the best interventions for transferring patients to a suitable LTC facility.