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Putting Feet First: DET OHT Unveils New Strategies to Reduce Lower-Limb Amputations

Masooma Raza · November 30, 2023 · Leave a Comment

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.

New Stepped Care Pilot Aims to Bridge Gaps in Mental Health Services – Part One

Masooma Raza · October 30, 2023 · 1 Comment

The Barriers to Mental Health Care

This news story is part one of the series on the DET OHT Stepped Care Pilot and highlights challenges in doctors' referrals and accessing individualized counselling and psychotherapy support.

Amid workforce shortage, accessing mental health support and services come with multiple challenges, including lack of one-on-one counselling and psychotherapy services tailored to individual needs, lengthy wait times, and timely referrals. According to the 2023 Ontario Association of Social Workers Survey of 1,265 adults, 10 per cent said that they tried but were unable to access mental health support. Their reasons for inaccessibility included long wait lists (60 per cent), high costs (38 per cent) and not having a referral from a family doctor (33 per cent).

Sara Al-Qasir, a mental health navigator with the Stepped Care Pilot and St. Michael’s Hospital Seamless Care Optimizing the Patient Experience (SCOPE) program, sheds light on the challenges.

Some local organizations are currently holding group counselling sessions. While that is a good option, many clients are looking for timely individualized counselling for their recovery."

In her interactions with clients/patients, Sara has noticed that patients were not only managing challenges with depression and anxiety, they experienced additional stressors from financial barriers, transportation needs, cultural and language differences, and mental health stigmatization.

Clients/patients is not the only group facing accessibility challenges. Initial interviews conducted by the stepped care project team to understand family physicians’ needs revealed family doctors also face accessibility challenges when seeking counselling or psychotherapy services for their patients with anxiety and depression.

The considerable administrative tasks associated with seeking appropriate referrals often cause family physicians to handle them themselves, diminishing the quality of interaction between a family doctor and a patient.

By introducing a mental health navigator in the referral pathway, the stepped care model relieves some of the commonly occurring and significant challenges for both patients and family doctors, while also making effective use of the health system’s resources.

Sara mentioned the mental health navigator’s role having a four-pronged approach;

  • Case management: Ensuring patients feel supported, developing care plans, following up every 2-3 weeks, and relaying information back to family doctors
  • Brief-talk therapy: Ensuring clients can cope with distressing situations and routine challenges by talking to a trained professional while they wait for specialized care
  • Customized care: Providing accessible list of resources tailored to the patient’s needs and circumstances
  • Warm transfer: Assisting with a three-way call to support patients with completing intakes over the phone, allowing them to build confidence and trust newly found resources

Each step focuses on improving the quality of patients' lives and adding value to the patient-doctor relationship.

32 family physicians, all members of the DET Family Practice Network and registered with the St. Michael’s Hospital SCOPE program, have enrolled in the pilot.

Participating physicians have collectively referred 243 clients to the mental health navigator, allowing the navigator to provide over 544 counselling sessions between April 2022 and October 2023.

While the project team continues to evaluate the impact of the pilot on patient experiences and outcomes, it is clear in the initial phase of the implementation that the pilot has allowed synergies between family physicians and the mental health navigator.

The project team aims to use their findings to inform the long-term growth and sustainability of the Stepped Care Pilot and similar programs. This will ensure that the positive outcomes not only benefit the local community, but also contribute to the broader mental health landscape.

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