Use data to understand the population most at risk for ALC designation and the care that they require

• Access Wait Time Information System (WTIS) data, monthly reports, etc.
• Conduct asset mapping to understand the current- state capacity of services available for the population most at risk

Include patients and caregivers as part of the care team

• Develop care plans and goals of care collaboratively with patients and caregivers.
• Implement an approach to measuring patient and caregiver experience and outcomes.

Optimize processes for early identification, assessment, and care plan development prior to ALC designation

• Use a screening process or tool to identify patients at risk of delayed transitions in care
• Identify and document patients’ baseline functional status
• Complete comprehensive assessment that addresses physical, cognitive, functional, and psychosocial domains
• Determine patients’ functional goals and restorative potential to inform the care plan
• Develop care plans to address identified care needs with a focus on transition to the community first.
• Implement evidence-based rehabilitative care pathways
  ALC Leading Practices Guide
  RCA & PGLO Framework for Rehabilitative Care for Older Adults Living with or at Risk of Frailty
  RCA Post-Fall Pathway: Emergency Department
  RCA Direct Access Priority Process

Deliver senior-friendly care interventions throughout admission

• Deliver a minimum standard of daily care (7 days per week) to all patients regardless of ALC designation or discharge destination
• Minimize risk of longer-than-expected lengths of stay by embedding evidence-based practices that actively mitigate the risk of avoidable deconditioning, falls, delirium, etc.
• Provide quality care and support to patients with, or at risk of responsive behaviours or personal expressions
  Senior Friendly Care implementation resources for delirium prevention
  Senior Friendly Care implementation resources for mobilization
  Behavioural Supports Ontario

Ensure consistent application of the ALC definition

• Ensure accurate application of an ALC designation that considers patients’ restorative potential within the current accurate or post-acute care setting
• Provide training to ensure clarity about when to recommend an ALC designation
  CIHI Job Aid: Guidelines to support ALC designation by clinicians

Transition patients requiring palliative support back to the community

• Use evidence-based tools to identify individuals who would benefit from palliative care
  TheOntario Palliative Care Network’s Tools to Support Earlier Identification for Palliative Care outlines recommended tools that can be integrated into various settings of care
• Implement an evidence-based model of care for providing palliative care in community settings
  TheOntario Palliative Care Network’s Palliative Care Health Services Delivery Framework outlines recommendations to guide organization and delivery of palliative care and includes a patient pathway
• Foster collaboration and communication internally and across care settings to support discharge to home or to other dedicated end-of-life settings
  Explore virtual platforms for connecting with specialists or with patients, especially in remote areas (e.g., Ontario Telemedicine Network’s eConsult, eVisits, and Virtual Palliative Care programs)
• Reach out to your Regional Palliative Care Network to get information on supports and partners in your local area
• Share resources (staff, technology, or training opportunities) among partners in your region (e.g., sharing and co-funding a nurse practitioner among partners within a region, or holding regional educational events)

Transition patients requiring support to age in place back to the community

• Use evidence-based tools to identify individuals living with or at risk of frailty
  Provincial Geriatrics Leadership Ontario and the Ontario Collaborative for Aging Well have identified recommended frailty screening tools that can be integrated into various settings of care