Abstract
People with diabetes and peripheral vascular diseases are at an increased risk for lower limb amputations. These amputations can have a significant impact on quality of life and overall health. In primary health care, diabetes management is comprehensive but there remains a care gap in publicly-funded foot care that can provide an upstream and preventative approach to lower limb preservation. This care gap is particularly pronounced for vulnerable populations in the community, particularly Indigenous and under/precariously-housed people. The Barrie and Area Ontario Health Team (BAOHT) prioritized this population health need by developing and implementing a change initiative that was people-centered and collaborative across sectors. In Ontario, Canada, Ontario Health Teams (OHTs) are a newer model of intersectoral health care designed to provide integrated care. Through the OHT model, community organizations coordinate with OHTs as a unified team to provide integrated and cohesive care with a focus on population health. As such, the BAOHT was an ideal change agent to propose and implement a lower limb change initiative.
The Barrie and Area OHT engaged with policymakers to establish the need for this change initiative. An environmental scan revealed a high rate of amputations along with the care gap of publicly-funded foot care for at-risk individuals who have diabetes and peripheral vascular disease, particularly those who do not have a primary care provider, are under or precariously-housed, and Indigenous populations. There was also an identified lack of health human resources in the service area, particularly for chiropodists with different organizations in the region across sectors having difficulty with recruitment and retention. The BAOHT developed a collaborative capacity among organizational partners across health care sectors (i.e. acute, primary health care, and community partners) with co-creation of the program including patients, the Indigenous community and those with lived experience. The goal was to improve the population’s health through improved access to care and reducing health inequities.
As a result of this innovative work, a foot care program that is coordinated around the needs of the people in the community, particularly vulnerable and at-risk populations was developed and implemented. This program includes two foot care nurses, a consulting vascular specialist, primary health care consultation and education, and community partner support. The foot care nurses hold clinics in rotating locations across sectors and population needs, including in Indigenous clinics, homeless shelters, and primary health care settings. Significant learning has included the importance of rigorous indicators and evaluation methodology, sustainable funding models, advocating for dynamic timelines that look towards long-term upstream change, and innovative collaborative governance across sectors that is adaptive to organizational and community needs. Evaluation of the program is currently being done with the goal of expanding the program to other OHT populations that are marginalized and/or at high risk for amputations. Programs like this are an example of innovative people-centered collaboration and can be a model for integrated care that focuses on population health at a national and international scale.