How a new program frees up beds by helping patients stuck in hospital find care elsewhere

A new program in Toronto that accelerated its launch during the pandemic is helping free up hospital beds while providing transitional housing to vulnerable patients who need an alternate level of care, like Maria Manalo, who had been living in hospital for more than four years.

COVID-19 pushed number of Ontario alternate-level-of-care patients to ‘historic heights’

Maria Manalo, 59, lived in a hospital for more than four years and waited for an appropriate care setting for nearly a year and a half. (Evan Mitsui/CBC)

Maria Manalo spent more than four years living in a hospital room at The Centre for Addiction and Mental Health (CAMH), even though she didn't require hospital-level care for nearly a year and a half.

Today, she stays in a private room inside a CAMH facility that was transformed into an assisted-living space after the hospital moved its emergency department last year.

Manalo says living in the hospital was lonely and stifling. But now, she's creating new relationships and has found a greater sense of independence as one of 37 vulnerable alternate-level-of-care (ALC) patients moved out of hospital and into transitional housing as part of a new program called The Path Home. 

"In the hospital, I was more lonely especially because I don't have family here to visit me," Manalo said outside the facility in downtown Toronto. "The clients and staff [here] are nice to me because I'm nice to them. I have a lot of friends."

The program was launched by CAMH and LOFT Community Services, a non-profit that provides support for people with mental and physical health challenges, during the COVID-19 pandemic. It helps clear hospital capacity and provide care and housing for low-income ALC hospital patients with complex mental health and addictions needs.

Those who run The Path Home estimate they will eventually be able to move more than 100 people out of hospital this year. 

Maria Manalo is pictured in her private room. She says she eats and sleeps better in her new home than when she was living in hospital. (LOFT Community Services)

Patients are designated ALC when they occupy a hospital bed, but do not require hospital-level care. They are waiting to be placed in an appropriate setting like a long-term care home or rehabilitation facility. 

Over the last several years, the number of ALC patients has been rising in Ontario, but their impact, especially on hospital capacity, was brought to light more publicly during the COVID-19 pandemic as hospitals desperately tried to create space when a barrage of COVID-19 patients threatened the system with collapse. While hundreds were relocated during the pandemic, there are still approximately 4,000 ALC patients in Ontario hospitals and health experts say more needs to be in place to get them appropriate care.

In 2019, caring for ALC patients cost the province about $500 a day per patient, according to the Ontario Hospital Association.

"We're constantly looking at what can be done," said Marnie Escaf, a clinical vice president at the University Health Network (UHN). "In some cases, it may require adding capacity into the system. So, it's a very active agenda, a very collaborative agenda, but it's not an easy issue to solve."

The average wait time in hospital for an ALC patient in Ontario is around five months, but some patients with more complex cases, like Manalo, stay considerably longer.

Ontario's hospital system was under immense pressure even before COVID-19 with "hallway medicine" becoming the norm at some hospitals, a problem Premier Doug Ford promised he would end.

From a hospital bed to karaoke

Manalo was initially in hospital for seizures, depression, anxiety and high blood pressure. With help from staff, she's now able to complete daily tasks like laundry and making her own bed — things she couldn't do in the hospital.

She says she's excited about finally having her own walker and enjoys the activities offered, especially dancing to karaoke.

"I'm very independent here [compared] to the hospital," Manalo said. "I can sleep better, I can eat better."

Maria Manalo is pictured outside the Centre for Addiction and Mental Health facility where she now stays. She says there are many activities to participate in and she particularly enjoys dancing to karaoke. (Evan Mitsui/CBC)

The Ontario Hospital Association says during the pandemic the number of ALC patients peaked at "historic heights" of 5,300 patients twice during the pandemic: once in mid-June 2020 and again in mid-February 2021. At those times, they made up between 16.5 to 18 per cent of beds.

Ontario Health says the GTA Alternate Level of Care Response Table was established during the pandemic to help identify hospital capacity pressures, come up with recommendations on directing where and how ALC and post-acute patients should be transferred and work with community providers who accept ALC patients.

During the pandemic, long-term care homes were urged to make space for ALC patients and in April the Ontario government enacted an emergency order allowing hospitals to transfer ALC patients to long-term care homes without their consent.

The Ontario Hospital Association says since the directive was put in place approximately 3,400 ALC patients have been transferred out of Ontario hospitals, but it's unclear which were moved under the emergency order.

Ontario Health says thanks to ongoing work, ALC patient rates have remained stable throughout the pandemic. It says between April 2019 and March 2020 ALC patients made up 16.2 per cent of patients in Ontario hospitals ,while that number grew slightly to 16.7 per cent during the same period this past year. 

Improvements in hospital capacity, but space still needed 

While COVID-19 hospitalizations continue to drop and non-emergency procedures gradually resume, Ontario hospitals are now up against a massive backlog of nearly 16 million medical procedures and Escaf hopes continuing to move ALC patients will help.

"We really have a focus now to look at how do we correct the backlog," she said.

So far, three UHN patients have been transitioned out of hospital as part of The Path Home, according to Escaf. She says the program is particularly helpful because it allows ALC patients with complex needs including behavioural issues to receive care in an environment better suited to them compared to a hospital. 

"It would be a win-win for both the hospital setting as well as the patients from a respect and dignity perspective to have those patients placed elsewhere," she said.

Health-care workers move through the intensive care unit at Scarborough Health Network’s Centenary Hospital, in north-east Toronto, on Apr. 8, 2021. (Evan Mitsui/CBC)

The program has also eased pressures at CAMH; at its peak, ALC patients made up a quarter of patients there, but since the program began in March, that number has gone down to 15 per cent, according to its president and CEO.

Catherine Zahn says at this stage in the pandemic people are waiting longer before they access CAMH's emergency department, which means the rate of admission is higher than usual and more space needs to be available.

"They're waiting as long as they can and they're coming to the hospital in a more serious state," she said. 

"We have a number of individuals who need care, who are in crisis, who require crisis and critical care, and to be able to free up space in the hospital to accommodate those who are acutely ill is a contribution to the whole mental health-care system," she said.

Program accelerated due to COVID-19

LOFT has been transitioning ALC patients out of 22 Toronto-area hospitals for years and plans to move 400 people in 2021 alone. The Path Home is its newest program and started accepting patients earlier than planned due to the pandemic and the need to free up hospital beds.

An empty space in CAMH's College Street location was quickly renovated to welcome patients with accessible washrooms, a dining hall and common area.

"COVID has brought a light to a lot of things and one of those things is hospital capacity and the need to create innovative, creative options to have people use hospitals for what they're designed for — crisis care, acute care needs," LOFT CEO Heather McDonald said.

The program is specifically designed for ALC hospital patients who have nowhere else to go and have complex needs, including mental health, addictions, behavioural issues and other psychosocial barriers. Some are facing homelessness and have both mental and physical health challenges.

The launch of The Path Home program was accelerated during the pandemic to help clear hospital beds. A floor inside a CAMH building on College Street in Toronto was renovated to create a living space for patients. (Evan Mitsui/CBC)

"Together, there isn't a place adequately designed to serve them," McDonald said. "[The Path Home] is a more dignified environment to allow people to express their independence."

The average time the program's patients were waiting in hospital for an appropriate care setting is just shy of two years. 

As is the goal with all ALC patients, The Path Home works with its clients to prepare them to live as independently as possible. After three to 12 months in the program, they'll transition to either a long-term care facility, community housing or one of LOFT's supportive housing programs.

Manalo says she's learning a lot about her health and how to live more independently but, while she enjoys the program, she says she looks forward to when she's discharged.

"They help me with everything I need until I can be independent again."


Angelina King is a reporter with CBC Toronto's enterprise unit where she covers a wide range of topics. She has a particular interest in crime, justice issues and human interest stories. Angelina started her career in her home city of Saskatoon where she spent much of her time covering the courts. You can contact her at or @angelinaaking


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