Concept: Alternate Level of Care (ALC) Patients - Method of Identification
Last Updated: 2014-04-21
1. Coded ALC Patients
All ALC patients should have the following coded on their hospital abstract:
- at least one ALC Reason Code;
- at least one ICD-10-CA diagnosis Z code that indicates the reason for ALC designation; and
- a Main Patient Service Code or a Service Transfer Code = 99 (ALC).
Additional criteria include:
- ALC patients must be designated ALC by their attending physician or an authorized delegate (Canadian Institute for Health Information (CIHI), 2010).
- an acute level of care (LOC) code (0-6) should be recorded. As of April 1, 2010, some non-acute levels of care are permitted to code ALC. These include: Chronic (code 3), Mental Health (code 5) and Rehab (code 2).
ALC Reason Codes
In Manitoba there are five major categories of ALC Reason Codes for why a patient is designated as ALC and each patient can be assigned up to three ALC Reason Codes in one hospitalization. The group code values and description for each of the major categories are:
- 10 - Panel Process for possible placement in PCH or Chronic Care facility;
- 20 - Waiting for Home Care or Community Care Services;
- 30 - Waiting for other placement such as a group home, supportive housing or hospice;
- 40 - Waiting due to other reasons such as respite, as a boarder baby or boarder mother or awaiting support or accommodation; and
- 50 - Rehabilitation Services (WHRA only).
Each major category has specific detailed codes that should be recorded in the abstract. Major group code values should not be recorded in the abstract. For a complete listing of all ALC Reason Codes see the ALC Reason Code definition in Fransoo et al. (2013).
On/Off Dates and ALC Length of Stay (ALCLOS)
For each ALC Reason Code there should be a corresponding set of "on and off" (start and stop) dates. These are recorded in the variables: alc_ondt1 to alc_ondt3 and alc_offdt1 - alc_offdt3. These variables can be used to calculate the ALC length of stay (ALCLOS). Beginning with 2007/2008 hospital data, a variable ALCLOS is also available. ALCLOS is the total number of hospital days designated as ALC for that hospital stay.
ALC-Related Z Codes
The Z codes are part of the International Classification of Diseases (ICD-10-CA) diagnoses codes that fall under the category "Factors influencing health status and contact with health services." These codes do not assign a diagnosis due to illness or injury, but rather provide supplementary information as to the patient's status and/or reason for admittance to or remaining in the hospital. Examples include routine physical examinations, vaccinations or outcome of delivery.
There are certain Z codes that are related to Alternate Level of Care (ALC), but they are not limited to ALC designation and may be used for any patient. Every patient designated ALC should have an ALC-related Z code in their hospital abstract to indicate the reason the patient was designated ALC. Coded ALC patients may have one or more ALC-related Z code recorded to indicate the reason for ALC designation (Canadian Institute of Health Information, 2010).
For a listing of ALC-related Z codes used in Fransoo et al. (2013), see the Z Code definition.
2. Possible ALC Hospitalizations
"Hospitalizations or days of hospital care categorized as Possible ALC (rather than Coded ALC) are those for which the patient did not have an ALC Reason Code included on their hospital abstract, and was not designated as Alternate Level of Care (ALC), but due to markers in the data may possibly have been a non-acute patient for some portion of their acute care hospital stay. Due to possible under-coding of ALC patients, it may be the case that properly coded ALC hospitalizations and days of care are a subset of the true number of non-acute patients occupying acute care hospital beds." (Fransoo et al, 2013).
In an attempt to identify additional hospitalizations and days in care that were likely non-acute, or possibly ALC, several algorithms were employed, in a hierarchical fashion, to identify these patients. Additional data files were used to assist in this investigation, including the Long Term Care (LTC) Utilization History Data, Home Care Utilization History Data and Home Care Minimum Data Sets (MDS) Assessment Data. The Need to Know Team project Team identified 4 different possible scenarios for non-coded ALC patients:
- PCH Admissions - these are patients directly discharged from hospital into a PCH and not coded as ALC in their abstract;
- New Home Care Cases - this includes people who did not have an open Home Care case on the day they were admitted to hospital but did on the day they were discharged from hospital. People in this group most likely had their discharge delayed somewhat, due to the process of arranging Home Care. This may not be true in all cases, but some of these patients should have been coded ALC during their stay.
- Diagnoses codes - some Z codes are closely related to ALC patients, and patients were labelled Possible ALC when they had not been coded as ALC, but did receive an ALC-related Z code. NOTE: Table 3.4 shows the distribution of ALC-related Z codes used to identify possible ALC cases.
- Diagnoses Codes and Service Transfer Codes - some of the patients in group 3 Diagnosis codes listed above also had Service Transfer Codes that specified the number of days of hospital care spent in each Service Type. These codes and dates determined the number of Possible ALC days of care involved.
For more detailed information on identifying possible ALC hospitalizations, please read the section titled Possible ALC Hospitalizations and Days of Care in Fransoo et al. (2013).
ALC Algorithm Hierarchy
The algorithm used to identify all ALC patients and ALC days of care, including both coded ALC cases and possible ALC cases is:
- Identify ALC patients using the Coded ALC method described above, looking at ALC reason codes, ALC start date and Z codes.
- Patients assessed for PCH placement during their hospital stay, and then admitted to PCH within ± 3days of discharge will have the time in hospital from panel date onward allocated as ALC days. Additional days will be allocated for time waiting to be paneled. This was allocated as 24% of patient's stay based on fully-coded ALC patients with ALC reasons 11 and 12 coded).
- Patients with a new home care case opened within ± 5days of discharge will have a portion of the time in hospital allocated as ALC days.
- Patients with an ALC-related Z code and corresponding diagnosis type W, X or Y (for 1st, 2nd or 3rd service transfer diagnosis) will have the service transfer days allocated as ALC days.
- Patients with only an ALC-related Z-code will have a portion of their hospital stay allocated as ALC days. The number of days allocated is specific to each Z-code, and is based on the proportion of time that fully-coded ALC patients with the same Z-code spent in hospital as ALC rather than acute. Column 3 (Percent of Hospitals Days Allocated as ALC) in Table 3.4 lists the percent of total days allocated to ALC for these cases.