Acute care inpatients with long-term delayed-discharge: evidence from a Canadian health region
Open accessAbstract
BACKGROUND: Acute hospital discharge delays are a pressing concern for many health care administrators. In Canada, a delayed discharge is defined by the alternate level of care (ALC) construct and has been the target of many provincial health care strategies. Little is known on the patient characteristics that influence acute ALC length of stay. This study examines which characteristics drive acute ALC length of stay for those awaiting nursing home admission. METHODS: Population-level administrative and assessment data were used to examine 17,111 acute hospital admissions designated as alternate level of care (ALC) from a large Canadian health region. Case level hospital records were linked to home care administrative and assessment records to identify and characterize those ALC patients that account for the greatest proportion of acute hospital ALC days. RESULTS: ALC patients waiting for nursing home admission accounted for 41.5% of acute hospital ALC bed days while only accounting for 8.8% of acute hospital ALC patients. Characteristics that were significantly associated with greater ALC lengths of stay were morbid obesity (27 day mean deviation, 99% CI = ±14.6), psychiatric diagnosis (13 day mean deviation, 99% CI = ±6.2), abusive behaviours (12 day mean deviation, 99% CI = ±10.7), and stroke (7 day mean deviation, 99% CI = ±5.0). Overall, persons with morbid obesity, a psychiatric diagnosis, abusive behaviours, or stroke accounted for 4.3% of all ALC patients and 23% of all acute hospital ALC days between April 1st 2009 and April 1st, 2011. ALC patients with the identified characteristics had unique clinical profiles. CONCLUSIONS: A small number of patients with non-medical days waiting for nursing home admission contribute to a substantial proportion of total non-medical days in acute hospitals. Increases in nursing home capacity or changes to existing funding arrangements should target the sub-populations identified in this investigation to maximize effectiveness. Specifically, incentives should be introduced to encourage nursing homes to accept acute patients with the least prospect for community-based living, while acute patients with the greatest prospect for community-based living are discharged to transitional care or directly to community-based care.
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ALC length-of-stay tends to increase with age.
“This counterintuitive finding can be explained by the tendency of ALC length-of-stay to increase with age.”
From Estimating the Cost of Alternate Level of Care When It Is Inextricably Linked to the Cost of Acute Care: A Canadian Example (2026) · cites this paper as Costa et al. 2012
The Results (page unavailable) report the opposite pattern among ALC patients waiting for nursing home admission: those under 65 and those aged 65–74 had significantly longer ALC stays, while those aged 85–95 had significantly shorter stays. This does not support a tendency for ALC length of stay to increase with age. (LLM, conf=0.90)
Checked by a reasoning model — may be wrong.
Experimental — accuracy not yet measuredALC patients frequently occupy a substantially higher proportion of hospital bed-days.
“ALC patients frequently occupy a substantially higher proportion of hospital bed-days (Victor et al. 2000;Costa et al. 2012).”
From Estimating the Cost of Alternate Level of Care When It Is Inextricably Linked to the Cost of Acute Care: A Canadian Example (2026) · cites this paper as Costa et al. 2012
The Results report that patients waiting for nursing home admission made up 8.8% of ALC patients but accounted for 41.5% of acute-hospital ALC bed days. This supports a disproportionate share for that subgroup, not the broader claim about ALC patients’ share of all hospital bed-days or how frequently this occurs. (LLM, conf=0.84)
Experimental — accuracy not yet measuredIn a cohort of 17,111 inpatients, 65% of those awaiting nursing home admission were prescribed psychotropic medications, with dementia prevalent but other neurological conditions rare.
“In a cohort of 17,111 inpatients, 65% of those awaiting nursing home admission were prescribed psychotropic medications, with dementia prevalent but other neurological conditions rare (Costa et al. 2012).”
From Dementia and Delayed Hospital Discharges: Assessing the Post-Discharge Care Gap for Older Adults in Canada. (2026) · cites this paper as Costa et al. 2012
ALC reflects a fundamental mismatch between patients' needs and the availability of necessary post-discharge care services.
“The ALC reflects the fundamental mismatch between patients' needs and the availability of necessary post-discharge care services (Costa et al. 2012).”
From Estimating the Cost of Alternate Level of Care When It Is Inextricably Linked to the Cost of Acute Care: A Canadian Example (2026) · cites this paper as Costa et al. 2012
Older ALC patients spend a larger portion of their hospital stay in ALC compared to younger patients.
“Consequently, older ALC patients spend a larger portion of their hospital stay in ALC compared to younger patients (Costa et al. 2012;CADTH 2024).”
From Estimating the Cost of Alternate Level of Care When It Is Inextricably Linked to the Cost of Acute Care: A Canadian Example (2026) · cites this paper as Costa et al. 2012
The Results report ALC length of stay by age, but not the portion of each age group's total hospital stay spent in ALC. They find longer ALC stays among patients under 65 and aged 65–74, and shorter stays among those aged 85–95; those absolute lengths do not establish the claimed comparison of proportions. I searched for an age-stratified comparison of ALC days with total hospital stay. (LLM, conf=0.76)
Experimental — accuracy not yet measured
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- Authors
- Costa, A. P., Poss, J. W., Peirce, T., & Hirdes, J. P.
- Affiliations
- University of Waterloo (CA)
- Corresponding author
- Costa, Andrew P
- Venue
- BMC Health Services Research
- Published
- 2012-06-22
- Volume
- 12
- Issue
- 1
- Pages
- 172-172
- ISSN
- 1472-6963 (ISSN-L)
- PMC
- PMC3424132
- OpenAlex
- W2026306668
- Cited by
- 132
- References
- 53
- Citations by year
- 2026: 5 · 2025: 11 · 2024: 9 · 2023: 13 · 2022: 13 · 2021: 18 · 2020: 11 · 2019: 16 · 2018: 7 · 2017: 8 · 2016: 8 · 2015: 6 · 2014: 4 · 2013: 3
- FWCI
- 7.39
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Licence
- Locations
- BMC Health Services Research (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- Public Health Agency of Canada
- Ontario Ministry of Health and Long-Term Care
- Public Health Agency
- Canadian Institutes of Health Research
- Topics
- Health Sciences › Health Professions › General Health Professions › Geriatric Care and Nursing Homes
- Health Sciences › Medicine › Emergency Medicine › Hospital Admissions and Outcomes
- Health Sciences › Medicine › Emergency Medicine › Emergency and Acute Care Studies
- Keywords
- alternate level of care, delayed hospital discharge, nursing home admission, length of hospital stay, morbid obesity, psychiatric diagnosis, abusive behavior, stroke, home care, nursing home capacity, care transitions, community-based care
- MeSH terms
- Activities of Daily Living, Acute Disease, Aged, Aged, 80 and over, Bed Occupancy, Catchment Area, Health, Female, Health Services for the Aged, Home Care Services, Hospitalization, Humans, Inpatients, Length of Stay, Long-Term Care, Male, Middle Aged, Nursing Homes, Ontario, Patient Discharge, Retrospective Studies, Time Factors, Waiting Lists, Evidence-Based Medicine
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