A project from the Downtown East Toronto Ontario Health Team (DET OHT) is implementing new tools to help improve foot screening for people living with diabetes and vascular conditions in the downtown core.
The fear of losing a limb is often profound for people living with diabetes and peripheral artery disease. According to a study, peripheral artery disease and diabetes, together, account for more than 80 per cent of lower limb amputations in the country. However, regular foot screening can be a major contributor in preventing most amputations and foot complications.
While analyzing the care gaps in the downtown core, the Lower Limb Preservation (LLP) project team within the DET OHT uncovered significant disparities in the preventive and timely delivery of foot care. They recognized challenges encountered by both clients and providers in accessing support services and navigating the complex health care system.
The analysis underscored the need to have a simpler process of screening and referring patients with foot wounds and complications.
In primary care consultations of clients with diabetes and vascular conditions, foot screening often takes a back seat to other complications, such as stroke, coronary ischemia, blindness, and kidney damage. To encourage timely screening, the LLP team at the DET OHT has developed a foot screening and risk management instrument for providers. It allows them to follow three simple steps: 'Look' for wounds, ulcers, and signs of gangrene; 'Touch' and check palpable blood flow in the feet; and 'Ask' about pain in the resting position of feet and/or toes.
The outcomes from these steps assist providers in determining the subsequent stages in a client's foot care journey, ranging from education for low-risk patients to directing high-risk individuals to specialized clinics.
"Patients may not be fully aware of the risks and importance of foot health, and they often struggle to determine when and where to seek help for foot-related concerns," says Sandra Fitzpatrick, Regional Facilitator for Toronto Diabetes Care Connect, a regional program led by South Riverdale Community Health Centre.
While there are numerous barriers hindering timely and appropriate access to foot care, Sandra says financial constraints are a significant challenge. Many individuals need to pay out-of-pocket for chiropody and foot care services and find it exceedingly difficult to afford private foot care. As a result, they face barriers in accessing preventive foot care and resort to overcrowded hospital emergency rooms, if complications develop.
Similar to primary care, specialized foot care is also facing overwhelming demands.
"Chiropody clinics are operating at full capacity,” says Teresa Salzmann, a chiropodist at Anishnawbe Health Toronto, who provides specialized care to vulnerable individuals in the Indigenous community. “Over the last couple of years, there has been a significant increase in moderate to high-risk cases that require escalation of care.”
Experts in the field say clients accessing specialized foot care experience varied and lengthy clinical journeys, and may fall through the cracks.
Fitzpatrick and Salzmann have played a key role in enhancing the efficiency of client navigation. Together with clients, who offered valuable firsthand insights into challenges accessing foot care, they have developed a visual pathway outlining prognoses and corresponding actions. This helps providers to take appropriate measures to mitigate the risk of complications and potential amputations. Additionally, the pathway recommends specialized referral clinics to primary care providers participating in the program, catering to different types of wounds and complications identified during screening.
The LLP team has extended an invitation for participation to family physicians who operate outside of team-based settings and do not have access to specialized foot care, including Ministry of Health-funded chiropody clinics.
The main objective of the project is to ensure that everyone receives appropriate foot care at the appropriate time. To achieve this goal, the DET OHT aims to substantially reduce the number of lower-limb amputations over time. However, in the short term and with the help of measures enhancing screening and escalation of care, the team is focused on making foot care an equal priority as other complications of diabetes.