Lower Limb Preservation: Advancing Integrated and Equitable Community-Based Care in Northwestern Toronto, Ontario

Background: Individuals with diabetes and vascular disease face disproportionately high risks of avoidable hospitalizations, amputations, and long-term disability1. In Northwestern Toronto, an underserved community, these risks are compounded by systemic inequities, fragmented transitions between care settings, and limited access to vascular expertise. Addressing these complexities requires a proactive, integrated, and community-based approach prioritizing early intervention, coordinated care, and patient and provider engagement.

 

Approach: The Lower Limb Preservation (LLP) Pathway was co-designed by Humber River Health’s (HRH) SCOPE and LTC+ programs with vascular specialists at OwnHealth to strengthen continuity of care across hospital, community, and long-term care (LTC) sectors. SCOPE and LTC+ are virtual, interdisciplinary programs that connect primary care providers and LTC clinicians to hospital and community resources, offering navigation support and care coordination to enhance outcomes and foster collaboration.

 

A co-developed logic model and evaluation framework enabled data-driven improvement aligned with the Quintuple Aim, reflecting a shared commitment to equity, innovation, integrated care, and continuous quality improvement.

This innovative model embeds vascular expertise within community settings by incorporating hospital-based specialists with an interdisciplinary network, including nurse navigators, primary care providers, LTC clinicians, nurse practitioners, and chiropodists.

 

This collaborative design emphasizes early detection, coordinated triage, navigation, and streamlined referrals to reduce delays and improve clinical outcomes for individuals with vascular wounds.

HRH’s and OwnHealth’s investment into the LLP Pathway reflect a commitment to coordinated, person-centred, and equitable care across sectors. This includes enhancing access to specialized vascular expertise within the community, team-based collaboration, outreach to underserved populations to support health equity and inclusion, data-driven improvement through the utilization of a logic model and evaluation framework, and capacity-building through tools, training, and support for community-based vascular wound management. This investment enables a shift from reactive hospital-based interventions to proactive community-based approaches to care that preserve function and prevent avoidable limb loss. Strategic partnerships with the Northwest Toronto Ontario Health Team further enhance system navigation, provider collaboration, and alignment with regional health priorities.

 

Results: Through proactive, coordinated, interdisciplinary care, HRH’s LLP Program demonstrates reductions in major lower-limb amputations and limb preservation for patients at risk. Improved access to specialized vascular expertise—previously limited to acute hospitals—has reduced wait times and enhanced seamless care coordination across settings, decreased avoidable emergency department visits and hospitalizations, positively contributing to cost effective use of acute care resources, and patients’ experience and quality of life. Outreach to equity-deserving populations has expanded access to specialized care, closing long-standing gaps in limb preservation outcomes.

 

The LLP Pathway supports providers through timely consultations, educational resources, collaborative care planning, and wound management, reinforcing local capacity to manage complex patients in the community. Next steps include deploying patient experience surveys.

 

Implications: This presentation will outline the LLP Pathway’s evolution, early results, and lessons learned, highlighting implications for future investments in prevention and community-based support. Grounded in population-level data, community partnerships, and continuous quality improvement, the LLP Pathway offers a scalable framework for integrated care systems that advance health equity, quality of life, and hospitalization avoidance.

 

References

1.Corhealthontario.ca. Available from: https://www.corhealthontario.ca/Ontario_Framework_for_Lower-Limb_Preservation-October-2021.pdf.