New Brunswick ALC Hospital Discharge: Per Diem Fees, the First Offer Rule, and Fast-Track Placement

What ALC Means for Your Family

When a physician determines that a hospitalized parent is medically stable for discharge but cannot safely return home, the hospital designates them Alternate Level of Care (ALC). At that point, the parent no longer needs acute medical services — they need a long-term care bed that doesn't exist yet.

New Brunswick has some of the highest ALC occupancy rates in Canada. Between 21.2% and 32.4% of total hospital bed-days are occupied by patients who are medically cleared but stuck waiting for placement in a nursing home or special care facility. Your parent becomes part of that statistic the moment ALC status is assigned.

The financial and logistical pressure that follows is intense, and understanding the rules before you're in the middle of it gives families a critical advantage.

The Per Diem Charges

Once a physician signs the medical discharge and ALC status is assigned, Medicare coverage for the hospital stay ceases. The health authority begins billing a daily per diem fee for the bed.

At Horizon Health Network facilities, the current per diem rate is $57.15 per day — roughly $1,737 per month. This charge accumulates for as long as the parent remains in the hospital bed waiting for a long-term care placement.

Families have reported hospital per diem bills exceeding $20,000 when waitlists stretch to 12–18 months. The bills are issued by the health authority, not the hospital's patient accounts department, which adds confusion about who to contact for payment arrangements or disputes.

The per diem is separate from and in addition to whatever co-payment the family will eventually owe at the receiving long-term care facility. It's the cost of occupying a hospital bed that the system needs for acute patients.

The First Offer Rule (Regulation 85-187)

Under Regulation 85-187 of the New Brunswick Nursing Homes Act, ALC patients are subject to the first offer rule: they must accept the first vacant nursing home bed that becomes available within a 100-kilometre radius of their home municipality and matches their official language of choice (English or French).

That bed may not be at the family's preferred facility. It may be in a town an hour's drive from where the family lives. But under the regulation, refusing a valid first offer carries consequences:

• Loss of waitlist priority — the parent may lose their place on the waitlist
• Continued hospital billing — the per diem charges keep accumulating
• Potential discharge — the hospital can initiate discharge proceedings

The regulation does allow the family to select two preferred facilities when applying for placement. If a vacancy opens at one of those preferred homes, that offer takes priority. But the first offer rule applies when no preferred-facility bed is available and the hospital needs to free the acute bed.

Accepting an Interim Bed

Accepting a first-offer bed doesn't mean giving up on the preferred facility. Residents who accept an interim placement remain on the transfer list for their top-two choices. When a vacancy opens at a preferred home, the transfer is arranged.

This is the practical compromise most families land on: accept the interim bed to stop the per diem bleeding, then wait for a transfer. The interim facility provides subsidized care at the same rate structure as the preferred facility — the co-payment formula and provincial subsidy cap apply regardless of which facility the parent is placed in.

The risk families weigh is distance. An interim placement 80 kilometres from home means fewer visits, harder logistics, and a parent in an unfamiliar community. For some families that trade-off is manageable; for others — particularly when the parent has dementia and is distressed by unfamiliar environments — it's genuinely harmful.

The Fast-Track Ministerial Override

Under legislative amendments enacted in August 2025, the Minister of Social Development has fast-track authority to override standard waitlist order for up to 120 days when two conditions are met:

1. Hospital occupancy exceeds 95%
2. At least 25% of occupied beds are ALC patients

When the override is active, the Minister can direct placement of ALC patients into available long-term care beds regardless of normal waitlist position. The intent is to clear critical hospital capacity during surge periods — flu season, major health events, or regional crises.

For families, this means the standard waitlist order isn't always guaranteed. A parent who's been waiting for months at one position on the list can be leapfrogged during an override period. Conversely, a parent in ALC status during an override period may receive a placement faster than the normal timeline would predict.

What Families Can Do

The hospital discharge planner and social worker are the primary contacts during an ALC situation. They coordinate the functional assessment, connect the family with Social Development's financial assessment process, and manage the waitlist mechanics.

Three things that improve outcomes:

1. File the financial application form immediately — the 30-day deadline starts when it's issued, and delays push back the entire placement timeline
2. Ask about community-based alternatives — the Extra-Mural Program can sometimes provide enough clinical support at home to avoid or shorten the ALC period
3. Understand the first offer rule before it's invoked — knowing that you can accept an interim bed while staying on the preferred-facility transfer list removes the sense of permanence from a difficult decision

The complete ALC navigation strategy — including the per diem cost calculator, first-offer response scripts, and the interim placement transfer process — is in the New Brunswick Long-Term Care Costs & Subsidies Guide.

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