Diabetes Foot Care Project Draft Final Report · 2014-10-27 · 2 Draft Diabetes Foot Care Project...

Draft Diabetes Foot Care Project – Final Report Draft for Discussion

\\\\

Diabetes Foot Care Project Draft Final Report

June 6, 2014

PREPARED BY: MNP LLP

300 - 111 Richmond Street West

Toronto, ON, M5H 2G4

MNP CONTACT:Ian Brunskill

Partner, Health Practice Lead, Consulting

PHONE: 416-515-5052

FAX: 416-596-7894

EMAIL: [email protected]

Draft Diabetes Foot Care Project – Final Report Draft for Discussion

Table of Contents

Executive Summary ........................................................................................................................................ i

1 Introduction .......................................................................................................................................... 1

2 The Context for Change ........................................................................................................................ 2

3 Evidence-Based Best Practices .............................................................................................................. 5

4 The Current System of Diabetes Foot Care in London .......................................................................... 8

5 The Future System of Diabetes Foot Care in London ........................................................................... 8

5.1 Alignment with Health System Priorities .................................................................................... 11

5.2 Implications for Implementation ................................................................................................ 12

6 Implementation Plan .......................................................................................................................... 19

7 Implementation Plan for Expansion to the South West LHIN ............................................................. 26

8 Appendices .......................................................................................................................................... 27

i Draft Diabetes Foot Care Project – Final Report Draft for Discussion

Executive Summary

Foot problems are a major cause of morbidity in people with diabetes. Neuropathy, vascular

insufficiency, foot deformities and trauma predispose people with diabetes to foot ulcers. If not treated

appropriately, foot ulcers can take many weeks to heal and/or progress to severe infection and

amputation.i Poorly managed foot ulcers cause increased morbidity and mortality, and also cause a

large financial burden on the health system.

There are recognized evidence-based best practices in prevention, treatment, and management of

diabetes foot ulcers that, if implemented, not only improve patient outcomes but also reduce cost.ii

Evidence-based best practices are, in fact, being implemented across the London area according to

interviews with key stakeholders, yet, there is not an integrated approach to their application.

Diabetes is a chronic disease that affects approximately one tenth of the Canadian population. There

are approximately 85,500 people living with diabetes in the South West LHIN, and 42,000 are in the

London areaiii. The South West LHIN ranks above the provincial rates and goal rates set by the Ontario

Diabetes Strategy for amputation and hospitalizations for skin/soft tissue infection in residents. In order

to address these rates and improve outcomes of patients, the South West Local Health Integration

Network (South West LHIN) initiated the Diabetes Foot Care Project. This project involved the South

West LHIN working with its Health Service Providers (HSPs) to develop a service delivery model and

implementation plan for the prevention, treatment, and management of diabetes foot ulcers in all

individuals living with Diabetes in London, with the intent to adapt/spread the model for diabetes foot

care1 across the LHIN in the future. The consulting firm MNP was contracted to undertake this Diabetes

Foot Care Project.

Given the fiscal constraints within the health system environment, and the local and provincial priorities

of integration, the Project had a goal of “no-net-new” resources in the model developed; the model and

implementation plan were to include a re-alignment of services and resources to deliver best-practices.

The outcomes of the model and implementation plan were intended to:

Increase the quality of care for patients and decrease healing time

Reduce incidents of foot ulcers

Increase access to appropriate and timely care

Coordinate and standardize care

The work of the project was completed using an experience-based co-design approach. This leveraged

the extensive skills, expertise, and experience of stakeholder in the London area. Gated workshops

conducted with stakeholders informed the future state model and its implementation that are

summarized in this report.

1 Diabetes foot care in this context refers to the prevention, treatment and management of foot ulcers in people

with Diabetes

ii Draft Diabetes Foot Care Project – Final Report Draft for Discussion

The future state model is an integrated system level strategy to address diabetes foot care in the

London area, with an expansion plan to the South West LHIN, which is based on evidence-based best

practices. The future state model is aligned with both the Ministry of Health and Long Term Care

(MOHLTC) priorities and South West LHIN strategic directions. Figure 1 contains a conceptual

representation of the model. The future state model stratifies the risk of diabetes foot ulcers in three

levels: low, moderate, and high. The risk stratification would be determined through the application of

a harmonized risk assessment, and referrals are then discussed with the individuals and made as

appropriate based on a harmonized referral algorithm. The principles of the future state model are

listed in the white space of the conceptual model.

Figure 1: Conceptual Representation of the Future State Model of Diabetes Foot Care in London

The future state model will have implications to the health system that should be considered in its

implementation. The report outlines the implications for implementation for each of the risk

stratification levels of the model against eight factors: capacity and health human resources (HHR);

funders and funding structures; facilities and/or space; data/information management; data/tools; and

accountability for practice.

High Risk(Any of skin breakdown, past or present ulcer, or

amputation)

Moderate Risk(One or more of skin abnormality, structural deformity, limited mobility, loss of protective

sensation, vascular problems)

Low Risk(Absence of risk indicators) Evidence

Informed

Utilize Service Providers’ Full Scope of Practice

Person-Centred/ Patient -Focused

Leverage Existing Investments

Interdisciplinary

Self-Managed Approach

Integrated at the system

level

PreventiveDelivered in Conjunction with Optimal Diabetes

Control

Guided by the Social

Determinants of Health

CostEfficient

iii Draft Diabetes Foot Care Project – Final Report Draft for Discussion

A two year implementation plan for the future state model has been developed for the London area. An

implementation plan for the expansion of the future state model to the South West LHIN also has been

developed.

1 Draft Diabetes Foot Care Project – Final Report Draft for Discussion

1 Introduction

Foot problems are a major cause of morbidity in people with diabetes. Neuropathy, vascular

insufficiency, foot deformities and trauma predispose people with diabetes to foot ulcers. If not treated

appropriately, foot ulcers can take many weeks to heal and/or progress to severe infection and

amputation.iv Poorly managed foot ulcers cause increase morbidity and mortality, and also cause a large

financial burden on the health system. There are recognized evidence-based best practices in

prevention, treatment, and management of diabetes foot ulcers that, if implemented, not only improve

patient outcomes but also reduce cost.v

The South West Local Health Integration Network (South West LHIN) ranks above the provincial rates

and goal rates set by the Ontario Diabetes Strategy for amputation and hospitalizations for skin/soft

tissue infection in residents. In order to address these rates and improve outcomes of patients, South

West LHIN initiated the Diabetes Foot Care Project. This project involved the South West LHIN working

with Health Service Providers (HSPs) in its region to develop a service delivery model and

implementation plan for the prevention, treatment, and management of diabetes foot ulcers in all

individuals living with Diabetes in London, Ontario with the intent to adapt/spread the model for

diabetes foot care2 across the LHIN in the future. The consulting firm MNP was contracted to undertake

this Diabetes Foot Care Project.

Given the fiscal constraints within the health system environment, and the local and provincial priorities

of integration, the Project had a constraint of “no-net-new” resources in the model developed; the

model and implementation plan were to include a re-alignment of services and resources to deliver

best-practices. The outcomes of the model and implementation plan were intended to:

Increase the quality of care for patients and decrease healing time

Reduce incidents of foot ulcers

Increase access to appropriate and timely care

Coordinate and standardize care

This report is meant to provide an understanding of the context in which the Diabetes Foot Care Project

was undertaken, the work completed through the project, the future state model developed, and the

plan for the implementation of the model. It complements the current state assessment that is

summarized in the Diabetes Foot Care Project Workshop Background Document found in Appendix A.

The work of the project was completed using an experience-based co-design approach. This leveraged

the extensive skills, expertise, and experience of stakeholder in the London area. Gated workshops

conducted with stakeholders informed the future state model and its implementation that are

2 Diabetes foot care in this context refers to the prevention, treatment and management of foot ulcers in people

with Diabetes


summarized in this report. A description of the methodology used in the project can be found in

Appendix B.

2 The Context for Change

Diabetes is a chronic disease that affects approximately one tenth of the Canadian population. There

are approximately 85,500 people living with diabetes in the South West LHIN, and 42,000 are in the

London areavi. Diabetic foot lesions frequently result from two or more risk factors occurring together,

and in the majority of patients peripheral neuropathy plays a central role. Neuropathy can lead to a lack

of sensation and sometimes foot deformities that, in turn, can lead to abnormal walking patterns which

can cause lesions. Up to 50% of people living with type 2 diabetes have neuropathy and at-risk feetvii.

In the South West LHIN there are relatively high rates of diabetic foot ulcer diagnoses in patients with

diabetes who are inpatients in hospital or the emergency room (ER). Figure 2 shows the rate of foot

ulcer diagnosis, by type, per 100,000 population with diabetes in 2013/14. The rates for the South West

LHIN are higher than the Ontario rates, however, the London area has lower rates than Ontario.

Figure 2: Rate per 100,000 of People with Diabetes of Hospital Discharges and Emergency Room Visits, 2012/13 (for All Diagnoses and Most Responsible Diagnosis

viii

(MRD)ix

Similarly, the London area and South West LHIN have higher proportions of unscheduled emergency

room visits for diabetic foot ulcers for those with Type 2 diabetes than the provincial average; this

suggests that some of these patients might be unaware of health service options other than the ER, or

that a preventive encounter might have prevented the visit to the ER. The London area has a higher

proportion of unscheduled visits for Type 2 diabetes with foot ulcers than the provincial rate. Also, the

0

50

100

150

200

250

300

350

400

450

500

Discharges, All diagnoses Discharges, MRDx ER Visits, All diagnoses ER Visits, MRDx

Rat

e p

er

10

0,0

00

of

pe

op

le w

ith

dia

be

tes

London South West LHIN Ontario


South West LHIN has a higher proportion of unspecified diabetes with foot ulcers than the province.

These statistics are depicted graphically in Figure 3.

Figure 3: Proportion of Unscheduled ER Visits for Diabetic Foot Ulcers, Most Responsible Diagnosis (MRD), by Type, 2012/13

x

The South West LHIN has the third highest rate of amputation among Ontarians with diabetes (over 200

per 100,000) in comparison to other LHINsxi According to the American Diabetes Association, over half

of amputations related to diabetes are preventable. Of the Ontario LHINs, the South West LHIN has the

second highest rate of hospitalizations for skin/soft tissue infection among patients with diabetes (over

700 per 100,000)xii. In Canada, the estimated direct and indirect cost of an amputation is between

$35,000 and $50,000xiii.

For those individuals with diabetes who are hospitalized in London and the South West LHIN, the length

of stay in hospital is highly variable. Figure 4 shows the average total length of stay in hospital for

diabetic foot ulcers, by type, in London, the South West LHIN, and Ontario in 2012/13. Both London and

the South West LHIN have lower average lengths of stay for those with Type 1 Diabetes and foot ulcers

(both with gangrene and without) than Ontario. For those with Type 2 diabetes and foot ulcers,

however, the London area shows longer lengths of stay in hospital than Ontario or the South West LHIN.

Finally, for those with unspecified diabetes and foot ulcers, the average length of stay in hospital in the

South West LHIN is longer than that of Ontario.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Pro

po

rtio

n o

f ER

vis

its

Type 1 Diabetes w Foot Ulcer Type 1 Diabetes w Foot Ulcer w Gangrene

Type 2 Diabetes w Foot Ulcer Type 2 Diabetes w Foot Ulcer w Gangrene

Unspecified Diabetes w Foot Ulcer Unspecified Diabetes w Foot Ulcer w Gangrene


Figure 4: Average Total Length of Stay in Hospital for Diabetic Foot Ulcers, All Diagnoses, 2012/13

Diabetic foot ulcers are a source of major suffering and very high costs for both the patient and the

health-care system. The International Working Group on the Diabetic Foot (IWGDF) states that globally

more than one million people with diabetes lose a leg every year as a consequence of their condition.

This means that every thirty seconds a lower limb is lost to diabetes somewhere in the world.xiv The

IWGDF Editorial Board states that investing in diabetic foot care guidelines can be one of the most cost-

effective forms of health-care expenditure, provided the guidelines are goal focused and properly

implemented.xv Further, the IWGDF maintains that a strategy that includes prevention, patient and staff

education, multidisciplinary treatment of foot ulcers, and close monitoring can reduce amputation rates

by 49-85%xvi.

0

5

10

15

20

25

30

Type 1 Diabetes w Foot Ulcer

Type 1 Diabetes w Foot Ulcer w Gangrene

Type 2 Diabetes w Foot Ulcer

Type 2 Diabetes w Foot Ulcer w Gangrene

Unspec.Diabetes w Foot Ulcer

Unspec. Diabetes w Foot Ulcer w Gangrene

Ave

rage

to

tal

LOS

(in

day

s)



3 Evidence-Based Best Practices

There are numerous recognized evidence-based best practices in prevention, treatment, and

management of diabetes foot ulcers that may, if implemented, not only improve patient outcomes but

also reduce cost. The stakeholders consulted throughout this project, many of whom are published

themselves, stated that the various sources for evidence-based practice are well aligned and should be

implemented wherever possible in the future state model. Evidence-based best practices are, in fact,

being implemented across the London area according to interviews with key stakeholders; however,

there is not an integrated approach to their application.

The International Working Group on the Diabetic Foot (IWGDF) was founded in 1996 as a non-profit and

independent foundation. Its aim is to create awareness of diabetes and improve the management and

prevention of the diabetic foot.xvii In 2011, the IWGDF produced the most recent version of its Practical,

Specific and Consensus guidelines on the management and prevention of the diabetic foot. These are

available on the IWGDF website and they were published in the Diabetes/Metabolism Research and

Reviews. The best practices cited by the IWGDF are aligned with those of the Canadian Association of

Wound Care (CAWC), and those of the Registered Nurses Association of Ontario (RNAO) Reducing Foot

Complications for People with Diabetesxviii. For the purpose of this report, IWGDF best practices are used

to summarize best practices in diabetes foot care.

The IWGDF identified five key elements that underpin foot management. These five key elements are

best practices that should be included in overall management of diabetes; they are:

Regular inspection and examination of the at-risk foot

Identification of the at-risk foot

Education of patient, family, and healthcare providers

Appropriate footwear

Treatment of nonulcerative pathology

Nova Scotia has successfully implemented many of these evidence-based best practices through the

Diabetes Care Program of Nova Scotia. They have developed a simple risk stratification model, a referral

algorithm that leverages that model and supporting documents for patients, caregivers, and providers.

These have been operational since 2009; they are available on the Diabetes Care Program of Nova Scotia

website.xix The Diabetes Care Program of Nova Scotia provides guidelines for the frequency of foot

assessment for individuals with diabetes based on their risk stratification; these are presented in Table

1.


Table 1: Diabetes Foot Care Risk Stratification and Frequency of Assessment

Diabetes Foot Care Project Diabetic Foot Risk Stratification

IWGDF Diabetic Foot Risk Stratification

Frequency of Assessment

Low Risk

No skin abnormality

No structural deformity

No vascular problems

Protective sensation intact

Risk Group 0 o No neuropathy o No peripheral vascular

disease o No deformity

Risk Group 1 o Neuropathy o No deformity o No peripheral vascular

disease

Assess annually

Moderate Risk

Any one or combination of the following:

o Skin abnormality (skin barrier intact)

o Structural deformity o Limited mobility o Loss of protective

sensation o Vascular problems

Risk Group 2 o Neuropathy o One or both of

peripheral vascular disease and deformity

Assess every 4-6 months

High Risk

Any of the following: o Skin breakdown o Ulcer (past or present) o Amputation

Risk Group 3 o History pathology

Assess every 1-4 months (high risk

Assess every 1-4 weeks (ulcer)

The IWGDF put forward further evidence-based best practices for principles of ulcer treatment. These

apply to individuals with diabetes in the high risk stratification level with ulcers and/or skin breakdown.

These evidence-based best practices are listed below.

Relief of pressure and protection of the ulcer

Mechanical off-loading – the cornerstone in ulcers with increased biomechanical stress

Restoration of skin perfusion

Treatment of infection

Metabolic control and treatment of comorbidity

Local wound care, for which the most important aspects of wound management are:

Regular inspection

Cleansing

Removal of surface decries

Protection of the regenerating tissue from the environment set

Education for patients and relatives

Determining the cause and preventing recurrence


The IWGDF has also reviewed the application of its diabetes foot care best practices in the health service

environment and as such has developed best practices for foot care programs. It states that effective

organization requires systems and guidelines for education, screening, risk reduction, treatment, and

auditing. The ideal foot care program should provide the following:

Education for patients, caregivers, and healthcare staff in hospitals, primary care, and the

community

A system to detect all people who are at risk, with annual foot examination of all known patients

Measures to reduce risk, such as podiatry and appropriate footwear

Prompt and effective treatment

Auditing of all aspects of the service to ensure that local practice meets accepted standards of

care

An overall structure that is designed to meet the needs of patients requiring chronic care rather

than simply responding to acute problems when they occur (delivered through an

interdisciplinary team)

At the local London level, the results of the 2010 research project of the Interprofessional Diabetes Foot

Ulcer Team were published in the International Wound Journal.xx This project applied the best practices

outlined by the IWGDF and proved its efficacy in the London area. Their findings supported the delivery

of a diabetes foot care program through an interdisciplinary team, and that when best practices were

applied through this model, outcomes improved and cost to the health system could be diminished.

As there are a number of evidence-based best practice tools in existence and due to the need of

organizations to have tools that support their specific reporting requirements, the use of harmonized

tools has become a promising/leading practice. Harmonized tools and guidelines incorporate

standardized or normalized data elements to facilitate the pooling, reporting, and/or collection of

standardized/normalized data across organizations. Anecdotal evidence shows that harmonizing these

tools provides commonly understand pathways and tools that in turn result in better coordination of

care and patient outcomes.


4 The Current System of Diabetes Foot Care in London

There are a number of providers and health service organizations providing diabetes foot care for the

prevention, treatment, and management of ulcers in the London area, however, they tend to work

independently of one another. This fragmented and uncoordinated approach to diabetes foot care

leads to both gaps and duplication of services. These, in turn, can result in higher cost for services and

inconsistent outcomes which translate to decreased quality of care for the patient.

Appendix A contains the Diabetes Foot Care Project Workshop Background Document that summarizes

the current state assessment. This document was used by the workshop participants in the

development of the future state model and in the development of the implementation plan.

5 The Future System of Diabetes Foot Care in London

Through discussions at the workshops conducted with key stakeholders, it is clear that there is a shared

desire across the provider community to improve diabetes foot care so that, in the future, the care

delivery model is one that has the following principle, it:

Is an integrated, system-level service delivery model

Is based on a person-centred, preventive, and interdisciplinary team approach

Is in conjunction with optimal diabetes control

Supports the elements and principles of diabetes foot management and ulcer treatment as

identified by the IWGDF

Includes the evidence-based best practices of foot assessments, risk stratification, and

offloading in addressing diabetes foot management and ulcer treatment

Utilizes a harmonized risk stratification and referral algorithm

Has as a key consideration the social determinants of health

Leverages existing services and organizations with a constraint of “no-net-new” dollars

Utilizes the full scope of practice of practitioners

Is cost efficient through service delivery by the most appropriate provider

A conceptual representation of the model is described in Figure 5.


Figure 5: Conceptual Representation of the Future State Model of Diabetes Foot Care in London

The risk stratification levels of the future state model, as denoted by the circles in Figure 5 are well

aligned with the stratification of the IWGDFxxi. The circles denote a number of aspects of the model.

First, they are meant to demonstrate the number of individuals that will fall in each stratification level.

The circles are stacked on top of one another to represent that the individuals who are included the high

risk stratification are a subset of those that are in the low risk stratification. Thus this also represents

the number of individuals who would receive services associated with each risk stratification level; there

are a greater number of individuals with diabetes who will receive services associated with the low risk

stratification level than those at the high risk stratification level. Finally, the services provided to

individuals in each of the risk stratification levels become more specialized as the circle size decreases.

The language in the white space of Figure 6 represents the principles for the future state model.

In the future state model, the right care will be provided by the right provider at the right place – taking

into consideration the risk level of the client.

Low Risk. All primary care providers, homecare providers (CCAC), and Diabetes Education

Programsxxii (DEPs) will apply the harmonized risk tool for all patients living with diabetes

annually and refer as required. They will build the capacity to meet the needs of the estimated

40,000 individuals requiring their services.

High Risk(Any of skin breakdown, past or present ulcer, or

amputation)

Moderate Risk(One or more of skin abnormality, structural deformity, limited mobility, loss of protective

sensation, vascular problems)

Low Risk(Absence of risk indicators) Evidence

Informed

Utilize Service Providers’ Full Scope of Practice

Person-Centred/ Patient -Focused

Leverage Existing Investments

Interdisciplinary

Self-Managed Approach

Integrated at the system

level

PreventiveDelivered in Conjunction with Optimal Diabetes

Control

Guided by the Social

Determinants of Health

CostEfficient


Moderate Risk. Patients will receive diabetes foot care from an interdisciplinary team which

includes professionals such as a diabetes foot care provider, a social worker, a diabetes

educator, etc. Patients will be assessed at least twice a year using the harmonized risk tool, and

will be referred to appropriate services, as required based on the harmonized referral algorithm.

Moderate risk services will be located at sites within HSPs with interdisciplinary teams that

already offer services to diabetes patients (e.g. Diabetes Education Programs (DEPs), Community

Care Access Centre (CCAC) home care and Flex Clinics, family health teams (FHTs)). They will

complement the regular diabetes care being offered, and will leverage their interdisciplinary

services. Based on the referral algorithm, services will be provided as necessary by a virtual

team of specialists (e.g. endocrinologists, surgeons). Sites will build the capacity to meet the

needs of the estimated 20,000 individuals requiring their services.

High Risk. The high risk service site will have many of the same attributes as the moderate risk

service sites, but also will have additional wound care capability through availability of a wound

care nurse, and a virtual team/itinerant specialists (wound care, infectious disease). Patients will

be assessed at least every one to four months if they are high risk and at least every one to four

weeks if there is skin breakdown and/or an active ulcer using the harmonized risk tool, and will

be referred to appropriate services, as required based on the harmonized referral algorithm

(e.g. endocrinologists, surgeons). There will be at least one fixed service location in London and

services may be offered on a itinerant basis in other locations (such as the moderate risk service

sites). The high risk service site(s) will have the capacity to meet the needs of the estimated

2,000 individuals requiring its services.

All stakeholders involved in the workshops supported the future state model concept. However, it is of

note that there was significant discussion around elements of evidence-based best practice that are out

of scope for this project but considered key to diabetes foot care. In particular, the discussion was

centred around the importance of off-loading in the prevention and treatment of diabetes foot ulcers.

Off-loading is accomplished through an individuals’ use of off-loading devices and/or equipment. These

are not currently funded through the Ontario Health System, which it was reported decreases access to

off-loading devices/equipment and results in less individuals with diabetes off-loading as prescribed by a

health provider. Therefore, the cost of procuring off-loading devices and services for individuals with

diabetes will continue to be a barrier to the treatment and management of diabetes foot conditions.


5.1 Alignment with Health System Priorities

The future state model is well aligned with both the Ministry of Health and Long Term Care (MOHLTC)

priorities and South West LHIN strategic directions. Diabetes foot care will, in majority of cases, be

addressed at a primary care level and addressing the diabetes foot care needs at the primary care level

is well aligned with the Ontario government primary care renewal. The focus of the primary care

renewal is person-centred care that is supported by increasing access to primary care; providing the

right care, at the right time, in the right place; and keeping Ontarians healthy. Further, the model’s

objectives of increased quality of care for patients and decreased healing time, and increased access to

appropriate and timely care support Ontario’s Action Plan for Health Care’s priorities of increased

access, “right care, right place, right time”, and keeping Ontarians healthy.

Further, Ontario has as one of its priorities to address complex chronic disease, of which diabetes is one.

The future state model addresses diabetes foot care and considers it a key component of overall

monitoring and maintenance of diabetes. In addition, the future state model aims to decrease the

complications of diabetes by preventing diabetes foot ulcers where possible and decreasing the time to

heal while increasing the quality of care to those who have diabetes foot ulcers.

A system-level service delivery model for diabetes foot care will also support the South West LHIN’s

strategic directions. Through achieving the project outcome of coordinating and standardizing care, it

will support the strategic direction to improve coordination and transitions of care for those most

dependent on health services. The future state model will also reduce redundancy and gaps and

improve quality of care and outcomes – increasing the value of the health care system for the people it

serves.


Figure 6: The South West LHIN's Integrated Health Service Plan 2013-2016 Strategic Directions and Big Dot Outcomes

5.2 Implications for Implementation

The future state model will have implications to the health system that should be considered in its

implementation. Outlined below are implications for implementation for each of the risk stratification

levels of the model against eight factors. These implications emerged based on the discussions of the

project stakeholders.


Capacity and health human resources (HHR) – the ability of the providers to meet the demand

(volume) for the future state model and the ability of the health human resources (HHR) to

meet the needs of the future state model through such things as their qualifications and

education

Funders and funding structures – the source(s) of funding for the provision of services and the

administration, governance, and implementation of funding

Facilities and/or space – the requirements relative to facilities and/space

Data/Information Management – the data captured and the collection and management of the

information derived from that data

Data/tools – the data required to be captured and communicated and the tools that enable that

process

Accountability for practice – the administration, governance, and implementation of practice

It is of note that although this project had the constraint of “no-net-new” funding, there is a

requirement for one-time transitional funding. This transitional funding is required for education of

existing health service providers in the system to gain the qualifications to provide diabetes foot care as

described in the future state. In addition, transitional funding is required for a resource to support the

implementation of the future state model.

Table 2 describes the implications for implementation. It outlines the current state, the future state,

and the change required to arrive at the future state.


Table 2: Implications for Implementation of the Future State Model

Risk Level Implications Current State Future State Change Required

Low Risk HHR and Capacity of HSPs

There is sufficient capacity in the system currently for front-line staff (e.g. nurses, PSWs, etc.) in primary care (including CCAC Flex Clinics and DEPs) to provide foot assessments to all 40,000 individual with diabetes annually

There is sufficient capacity of foot nurses available to provide foot care services (callus removal, nail filing, etc.)

There is a lack of knowledge in foot assessments and referral algorithms.

Existing front line staff in primary care are trained to perform foot assessment and use referral algorithm for all 40,000 individuals with diabetes in the London area annually

Training must be provided to front-line staff on the use of foot assessments and referral algorithms

All front-line staff in primary care to provide foot assessments and use the referral algorithm

Funders and funding structure

MOHLTC o Fee-for-service (FFS) (paid by OHIP) for

primary care o Program funding for multi-provider

primary care models

LHINs o DEPs o CHCs o AHACs o CCAC funding for Home Care and flex

clinic services

Client o FFS for foot care services outside of

those provided by CCAC or HSPs



primary care models


clinic services



None

Facilities/ space Delivered on site at a HSP or at home through the CCAC

Delivered on site at a HSP or at home through the CCAC

None

Data/IM CCAC captures data on foot assessments and referrals

Some HSPs capture data on foot assessments, referrals, and outcomes and referrals

Some specialists capture data on referrals, and outcomes

Standardized reporting to a long-term accountability structure of key stakeholders by all HSP, annually. This may include a snapshot of number of services provided (foot assessment, foot care, wound care), referrals, and outcomes

Standardized data elements for reporting annually must be agreed to. This may include a snapshot of: number of services provided (foot assessment, foot care, wound care), referrals, and outcomes



Data/tools CCAC uses normalized tools for foot assessments, and referral algorithms

Some HSPs use tools for foot assessments, and referral algorithms

All providers use harmonized tools for foot assessments and referral algorithms

Harmonized tools for foot assessments, and referral algorithms must be developed, implemented and used by all primary care providers

Accountability for practice

Independent accountability Independent accountability, and shared accountability supported by a long-term accountability structure of key stakeholders

A long-term accountability structure of key stakeholders must be established

Moderate Risk

HHR and Capacity of HSPs

There is sufficient capacity in the system currently for health services providers to provide foot assessments to all 20,000 individuals with diabetes and a moderate risk for diabetic foot annually

There is sufficient capacity of health service providers available to provide foot care services (callus removal, nail filing, etc.) based on current demand, although it is reported that demand is increasing

There is a lack of knowledge and education in foot assessments and referral algorithms

FHTs, DEPs, CHCs, AHAC and CCAC (home care and flex clinics) will provide interdisciplinary diabetes foot care services following best practices

Health service providers (e.g. personal support workers with appropriate education, foot care nurses, etc) at FHTs, DEPs, CHCs, AHAC and CCAC (home care and flex clinics) will provide foot care services to that full scope of practice

Partnerships will be developed with private providers for quality FFS services such as offloading

There will be a decrease in specialist visits because individuals will receive right care, at the right place, at the right time supported by the foot assessment and referral algorithm

While there are sufficient health professionals in the London area, to provide best practice foot care to the estimated 20,000 people at moderate risk, health professionals at each of the service provision sites need to be educated to provide foot care services.

Partnerships must be developed with private providers for quality FFS services such as offloading






primary care models


clinic services





primary care models


clinic services



Consider funding for health professionals with expertise in foot care to provide education, and mentoring other health care professionals

Continue to explore options to address costs of off-loading products and services

Facilities/ space Delivered on site at a HSP, where available, or at home through the CCAC

Delivered in existing facilities at DEPs, FHTS, CHCs, CCAC Flex Clinics, and AHAC

Delivered in the home through CCAC services

No additional facilities are required, however there may have to be changes to current facilities to accommodate foot care services such as aggressive debridement


Some HSPs capture data on foot assessments, referrals, and outcomes

and referrals


Standardized reporting to a long-term accountability structure of key stakeholders by all HSP annually. This may include a snapshot of number of services provided (foot assessment, foot care, wound care), referrals, and outcomes

Standardized data elements for reporting annually must be developed. This may include a snapshot of number of services provided (foot assessment, foot care, wound care), referrals, and outcomes










High Risk HHR and Capacity of HSPs

There is limited capacity (a sufficient number of providers to meet the demand) in the system currently for health service providers to provide wound care to all 2,000 individuals with diabetes and a high risk for diabetic foot annually

Although there is capacity, currently, not enough health service providers have the qualifications in wound care to provide sufficient services to meet the demand of the future state model

There is a lack of knowledge and education in foot assessments and referral algorithms

DEPs will provide interdisciplinary diabetes foot care services following best practices

Wound care nurses will be available the DEPs to provide wound care services

CCAC will continue to provide wound care services in the home

Partnerships will be developed with private providers for quality FFS services such as offloading

There will be appropriate use of specialist services because individuals will receive right care, at the right place, at the right time supported by the foot assessment and referral algorithm

While there are limited health service providers in the London area, to provide best practice foot care and wound care to the estimated 2,000 people at high risk without ulcers, health services provider at the site(s) providing services to people at high risk for diabetes foot ulcers need to be educated to provide the wound care services required

Partnerships must be developed with private providers for quality FFS services such as offloading




primary care models


clinic services





primary care models


clinic services



Consider funding for health professionals with expertise in wound care to provide education, and mentoring other health care professionals

Continue to explore options to address costs of off-loading products and services

Facilities/ space Delivered on site at a HSP, where available, or at home through the CCAC

Delivered in existing facilities at DEPs

Delivered in the home through CCAC services

No additional facilities are required, however there may have to be changes to current facilities to accommodate foot care services such as aggressive debridement. These changes would include sterile environments, sanitization equipment, foot care chairs, etc.




Some HSPs capture data on foot assessments, referrals, and outcomes

and referrals


Standardized reporting to a long-term accountability structure of key stakeholders by all HSP annually. This may include a snapshot of number of services provided (foot assessment, foot care, wound care), referrals, and outcomes

Standardized data elements for reporting annually must be developed. This may include a snapshot of number of services provided (foot assessment, foot care, wound care), referrals, and outcomes









6 Implementation Plan

This section presents a high level implementation plan for the Future State Model of Diabetes Foot Care

in London. Assuming the implementation plan begins to be executed immediately in order to build

upon the momentum and success of Diabetes Foot Care Project, the ten phases of the implementation

plan can be completed over the next two years (see Figure 7). The following table outlines additional

detail for each of the phases; based on the support for this system-level redesign and momentum

generated through the Diabetes Foot Care Project some activities of implementation are already

underway, and these are noted where applicable.


Figure 7: Implementation Timeline

Year 1 Year 2

3. Agreement from identified HSPs to realign resources to risk stratification model

1. Identify oversight structure to support implemen-tation

6. Realign existing resources within DEPs, FHT, and CCAC Home Care and Flex Clinics to provide moderate risk services

4. Agreement from HSPs to develop harmonized diabetes foot care tools

5. Create partnerships for private fee-for-service services

8. Engage health service providers in future state model and educate them as to the availability of services, and harmonized assessments and referrals/forms

10. Leverage existing tools and communication vehicles to educate public, clients, caregivers about Diabetes Foot Care and related services

2.Endorsement by key HSPs for shared management

11. Evaluate model

7. Realign existing resources within DEPs to provide high risk services


Implementation Steps Objective Key Activities Considerations Activities Already in Progress

1. Identify existing oversight structure to support the implementation of the Diabetes Foot Care Future State Model

To manage all aspects of the implementation of the Diabetes Foot Care Future State Model to ensure it is completed on time and with the continued participation of key stakeholders

Define the role of an oversight structure for the Diabetes Foot Care Project implementation, this should include project management

Identify an oversight structure for the diabetes foot care future state model

Transfer knowledge from Diabetes Foot Care Project to oversight structure

Oversight structure to manage all aspects of the Future State Model Implementation Plan

One-time transition funding is be recommended for a resource (such as an implementation coordinator) to support this role during implementation

The work that has taken place to date on the Diabetes Foot Care Project has set the stage for the implementation of the future state model of diabetes foot care in the London Area and this should be leveraged to move the project forward. This report can be used as tools by the identified oversight structure to “hit the ground running”. In addition, the momentum and support for the transition to the future state model that has been generated among stakeholders should be leveraged.

2. Obtain endorsement by key stakeholders (Health Service Providers) for shared-agreement

To gain the commitment of key stakeholders to execute the future state model through its shared- agreement.

Identify potential existing structures that could become the long-term accountability structure for the Diabetes Foot Care future state model

Work with identified potential existing structures to obtain agreement on becoming the long-term accountability structure for the diabetes foot care future state model. Responsibilities of the long-term accountability structure would be: o Work with the implementation coordinator (identified

in Phase 1) to ensure that the Future State Model is implemented

o Develop evaluation for the performance of the Future State Model

o Collect data for the evaluation of the Future State Model

o Determine how to include the necessary organizations and individuals in the Future State Model

The participants of the Diabetes Foot Care Project Workshops contributed to the development of the future state model through an experience-based co-design approach. As the key stakeholders involved have differing accountability structures and funding agreements, they have recognized that the future state model will have to be implemented and maintained through voluntary ongoing participation of all stakeholders involved.



3. Obtain agreement from identified Health Service Providers (HSPs) to realign resources as per the future state model

To gain the commitment of approximately five organizations to become sites for moderate risk services and one organization to become the site for high risk services for diabetes foot care that will provide the capacity needed for these services in the London Area.

Gain commitment of HSPs to provide these services

The long-term accountability structure, supported by the implementation coordinator, will work with the leadership of the organizations identified in the future state model to realign resources as required to support the service delivery outlined in the future state model

The HSPs identified to provide these services should be ones that currently offer interdisciplinary services to patients/clients with diabetes that will be leveraged for future state

These HSPs will need to consider how they could realign their service delivery model to support the new/increased foot care services. Responsibilities of the staff would most likely include foot assessments, provision of foot care, coordination of care and management of patient with other providers, education of patients, consultation to/with other providers, both internal and external, and referrals to other providers

The workshop participants felt that services for high risk individuals could be supported by a single HSP with a multi-disciplinary team.

Many of the organizations that are identified as a potential site for moderate and high risk services for diabetes foot care were represented in the Diabetes Foot Care Project and the Workshops, where the future state model was developed, and they expressed their interest in moving forward with the model. Activity has commenced at a number of the HSPs to realign resources to the future state model. One organization is already offering high risk services once per week.

4. Identify and obtain agreement from Health Service Providers to develop harmonized diabetes foot care tools

To create harmonized diabetes foot care tools that are based upon evidence-based best practices. These tools will include a standardized risk stratification model, as well as a harmonized foot assessment and referral algorithm. These tools will support the use of the standardized risk stratification through a diabetes foot assessment. A harmonized referral algorithm will support the harmonized risk stratification, and guide patients and providers to develop care plans.

Diabetes Foot Care oversight structure to leverage existing referral algorithms to identify and adopt/create a harmonized referral algorithm appropriate for Diabetes Foot Care in London

Based on the referral algorithm, the long-term accountability structure will identify the elements that must exist to harmonize foot assessment in the London and the surrounding area

The long-term accountability structure will capture the elements for harmonized tools and share with all organizations for their incorporation into practice. These organizations include but are not limited to CCAC, Primary Care Providers (both solo and group practice models), Community Health Centres, Aboriginal Health Access Centres, Diabetes Education Programs and Centres, Ontario Renal Network’s Socks Off Program, and Community Foot Care providers

The long-term accountability structure will develop a foot assessment form that includes the elements identified that may be used by sole practitioners and other providers (e.g. chiropodists) that do not have existing tools

The algorithm should be built upon the evidence-based best practices reported the International Working Group on the Diabetic Foot (IWGDF)

Where possible the long-term accountability structure will leverage resources that have already been developed, such as the resources from the Diabetes Care Program of Nova Scotia, Canadian Association of Wound Care (CAWC), and IWGDF (see Section 3 Evidence-Based Best Practices)

The tools should be developed as stand-alone tools for use by providers who do not have their own tools already developed

There are tools that have been developed by the IWGDF, the Diabetes Care Program of Nova Scotia, and the CAWC that can be leveraged to develop the harmonized tools for the London Area. The harmonized tools respect the need of stakeholders to develop and use their own tools. Harmonized tools ensure that the same risk stratification and referral algorithm is used by including standard elements is used by stakeholders across the London area.



5. Create partnerships for private fee-for-service services such as offloading and foot care services

To develop partnerships with private fee-for-service service providers to establish provider who are “affiliated” with diabetes foot care. These “affiliated” providers would have been reviewed for their ability to provide quality in services that support diabetes foot care (such as offloading and foot care services) based on their knowledge, skills, and experience.

Working with the long-term accountability structure , the implementation coordinator will oversee the development of partnerships with private services

Purpose of the partnerships is to create a registry of service providers who provide privately billed fee-for-service services related to diabetes foot care. These partnerships would then be used by providers to inform patients/clients of their options for quality privately billed fee-for-service services. These service providers are expected to include, but are not limited to Foot care services providers, e.g. chiropodists, podiatrist, foot care nurses, Offloading providers, e.g. orthotists, pedorthists

The partnerships would have to be reviewed on a regular basis so that they can be relied upon by providers to provide appropriate service and devices/equipment as per evidence-based best practices and referrals/prescriptions

The long-term accountability structure would have to determine the means of identifying high quality providers

There are private service providers in the London and surrounding area that are already recognized for their quality of services related to diabetes foot care. Further there are providers whose expertise the participants of the Diabetes Foot Care Project Workshops agree should be leveraged to assess the quality of these services.

6. Realign existing resources within DEPs, FHTs, and CCAC Home Care and Flex Clinics to provide moderate risk services

To build the capacity of the enlisted moderate risk service sites to provide the diabetes foot care services required to address the needs of the 20,000 individuals in London that may require their services. This includes building provider capacity and competency in providing diabetes foot care services, and internal capacity to support the interdisciplinary team and services offered to individuals with diabetes, such as social workers working with foot care providers and patients to assist in accessing funding for offloading, where necessary. Further, it includes building the virtual team that will provide services not provided at the sites, for example referrals such as vascular surgeon, offloading, endocrinology.

Implementation coordinator to work with the organizations that have enlisted in the future state model to train staff to provide services of the future state model

Implementation coordinator to work with the organizations to realign resources to provide sufficient access to services for the future care model, and to build the competencies that create capacity (Best practices state that an individual should be able to access these services within two weeks of referral)

Build virtual team by identifying appropriate providers for the virtual team (e.g. vascular surgeons, infectious disease specialists). Facilitate discussions between the organizations and the virtual team members to: o Establish an understanding of the risk stratification

model for service provision and the harmonized assessment and referral tools Establish understanding of the competency and capacity of the providers at the organizations providing moderate and high risk foot care services

Agree upon accessibility to virtual team members for consultation, referral, etc.

Funding may be available for the training of nurses through RNAO Education Funding o Nursing Education Initiative -

http://rnao.ca/education-funding/nei o Permanent Education Fund -

http://rnao.ca/education-funding/permanent-education-fund

A train-the-trainer approach has been suggested as a model to build capacity and skill development. Due to the complexity of diabetes foot care, including the potential for aggressive debridement, a mentoring type of approach to support training was seen as important by the working group

Workshop participants from the HSP sites recommended for providing moderate risk services have been involved in the Diabetes Foot Care Project and have indicated their interest in adding capacity to their skill set/teams to support the Future State Model. Also, many of the sites have established relationships with services providers that have been identified for the virtual team that can be leveraged as the future model is implemented.

http://rnao.ca/education-funding/nei





7. Realign existing resources within DEP(s)/HSP(s) to provide high risk services

To build the capacity of the recommended high risk service site to provide the diabetes foot care services required to address the needs of the 2,000 individuals in the London Area that may require its services. This includes building provider capacity and competency in providing wound care services, and building internal capacity to support the interdisciplinary team and services offered to individuals with diabetes, such as social workers working with foot care providers and patients to assist in accessing funding for offloading, where necessary. Further, it includes building the virtual team that will provide services not provided at the sites or arrange for itinerant providers to provide services, for example referrals such as vascular surgeon, offloading, endocrinology.

Work with the DEP that has agreed to be the high risk site to train staff to provide services outlined in the future state model

Work with the organizations to ensure that there is capacity in terms of access to services for the future state model. (Best practices state that an individual should be able to access these services within one weeks of referral when high risk and 24 hours when there is an ulcer present)

Build virtual team and, if appropriate, itinerant services by identifying appropriate providers for the virtual team, (e.g. vascular surgeons, infectious disease specialists). Facilitate discussions with between the organizations and the virtual team members/itinerant services providers to establish understanding of the competency and capacity of the providers at the high risk site(s)

Agree upon accessibility to virtual team members for consultation, referral, etc.

CAWC has courses for diabetes wound care that were identified as potentially very useful

It was suggested that training alone is not sufficient but that observation and guidance are necessary due to the complexity of diabetes and the need for aggressive debridement

A train-the-trainer approach has been suggested for building the skill set of nurses in wound care, wound care nurses and physician specialists may be appropriate providers of this education

Some work with the University of Western Ontario to provide medical student education in diabetes foot care has been undertaken to date, it was suggested that this be leveraged to provide increased training to both physicians and potentially nurses

Consider options for one time funding to provide training to the trainers and establish a sustainability plan for future funding

Front line providers from the St Joseph’s Health Care Primary Care Diabetes Support Program involved in the Diabetes Foot Care Project indicated interest in adding capacity to their skill set/teams. The St Joseph’s Health Care DEP was identified as the high risk service site in part because of its relationship to St Joseph’s Health Care and its access to patient information for those that are patients of both the hospital and the site. It is expected that these reasons for partnership will be fostered further and leveraged for the implementation of the Diabetes Future State Model.

8. Engage health service providers in the future state model and educate them as to the availability of services, and harmonized assessments and referrals/forms

To build the capacity of primary care providers to provide low risk services to the 40,000 individuals with diabetes in London and to build the capacity of other providers who will interact with the diabetes foot care future state model to apply the harmonized tools and provide access to services, as required. It is key to educate the providers as to how the future state model (including access to services and the harmonized tools) will assist them in providing an enhanced quality of care to their clients.

Leverage meetings of primary care providers, and emergency room providers to promote the diabetes foot care future state model

Circulate the harmonized risk stratification assessment and referral algorithm to all primary care and emergency room providers

Provide education sessions to educate providers on the use of the harmonized risk stratification assessment and referral

Relationships and networks with primary care providers, and emergency room providers should be leveraged to ensure that there is support to integrate the model in their care planning for people with or at risk of diabetes foot ulcers



9. Leverage existing tools and communication vehicles to educate public, clients, caregivers about Diabetes Foot Care and related services

To increase access to existing communication tools to educate public, clients, caregivers about Diabetes Foot care and services that will empower self-management and increase understanding of diabetes foot care.

Identify existing communication tools and media that can be used to educate public, clients, and caregivers about diabetes foot care and services and empower self-management

Inform public, clients, caregivers about diabetes foot care services and tools

Leverage the websites of the LHIN, CCAC, and moderate and high risk service sites, as well as the media, to provide access to identified tools

Many of these tools are already available for public use and therefore there should be few if any barriers to publishing/releasing the tools; examples of these tool are South West Health Line, MOHLTC “Managing Your Feet” video, Diabetes Care Program of Nova Scotia Foot Resources

The existing tools are already available to the public and these should be further promoted, tools could also be added to websites, etc. of moderate and high risk service sites.

The Diabetes Foot Care Project stakeholders identified several existing communication tools that support best practices that could be leveraged; these include:

Peer education programs such as the South West Self-management PEP program

CAWC’s Healthy Feet and You

St Joseph’s Primary Care Diabetes Support Program “I am Diabetic, How Do I Care for My Feet?” video

10. Evaluate diabetes foot care model

To build and implement a framework for measuring change and impact of the future state model on the incidence and duration of foot ulcers and will support future evidence-based decision making about diabetes foot care

Identify indicators of change and impact to be measured

Develop targets for change and impact of the diabetes foot care future state model

Develop data collection tools for moderate and high risk service sites as well as other access points for diabetes foot care services (such as primary care providers and ERs)

Inform all stakeholders of the tool for measuring change and impact, their benefit to using the tool, and the reporting period

Ensure all stakeholders are using the tool and reporting to the oversight structure

The oversight structure will evaluate the results based on the data provided and report back to stakeholders

To be able to accurately measure the impact of the future state model it will be key to have all stakeholders involved in providing diabetes foot care services provide their data for evaluation. This may require outreach and education to service providers particularly in primary care.


7 Implementation Plan for Expansion to the South West LHIN

The key attributes of the future state model described in this report should be applied to the entire

South West LHIN with relative ease.

In expanding the future state model to the entire South West LHIN, a number of items should be

considered. The first is that HSPs outside of the London area (with the exception of the CCAC and the

Renal Network) were not involved in the development of the future state model and it will be critical to

socialize, with the appropriate providers in the region, the future state model, the benefits of applying

it, and the implications for its implementation. The determination of the number of medium risk service

sites and high risk service site is required in the South West LHIN outside the London area requires

balancing factors such as the volumes/demand for services, the desire to provide care close to home,

and the need to ensure that the solutions are cost-effective and make best use of scarce clinical

resources; one option that was discussed in the workshops is having an interdisciplinary team available

at sites outside of the London area on an itinerant basis. Finally, technology should be leveraged where

possible to provide services to individuals close to home; examples include the use of telemedicine to

deliver diabetes foot care services and the use of the Ontario Telemedicine Network to support the

education of providers. These may decrease the cost of the services as well as improve outcomes.


8 Appendices

8.1 Appendix A – Diabetes Foot Care Project Workshop Background Document

i Draft Diabetes Foot Care Project – Final Report Draft for Discussion

South West LHIN Diabetes Foot Care Project December Workshop Background Document

December 10, 2013

PREPARED BY: MNP LLP

300 - 111 Richmond Street West

Toronto, ON M5H 2G4

MNP CONTACT: Ian Brunskill

Partner, Consulting

PHONE: 416-515-5052

FAX: 416-596-7894

EMAIL: ian. [email protected]

ii Draft Diabetes Foot Care Project – Final Report Draft for Discussion

Table of Contents

1 Introduction ......................................................................................................................................... iii

2 Context ................................................................................................................................................. iii

3 Current State Assessment .................................................................................................................... iv

3.1 Service Inventory ......................................................................................................................... vi

4 Critical Elements of the Future State Service Delivery Model for Diabetes Foot Ulcer Prevention,

Treatment, and Management ...................................................................................................................... xi

4.1 Education ..................................................................................................................................... xi

4.2 Interprofessional Teams .............................................................................................................xiii

4.3 Regular Foot Care and Lower Leg Assessments .......................................................................... xv

4.4 Access to Services ....................................................................................................................... xvi

5 Next Steps ......................................................................................................................................... xviii

iii

9 Introduction The South West Local Health Integration Network (South West LHIN) is working with its Health Service

Providers to develop a service delivery model and implementation plan for the prevention, treatment,

and management of diabetes foot ulcers in London. The work will include a plan to adapt the model for

spread across the LHIN in the future. The consulting firm MNP has been contracted by the South West

LHIN to undertake this project.

This document summarizes the key findings from the current state assessment to inform the future

state design for diabetes foot ulcer prevention, treatment, and management services in the London

area. It is not intended to be an in-depth report of the current state but instead to provide a high level

overview of the key considerations for the development of the future state model. It was developed as

a foundational document for the stakeholders participating in the current state workshop December 13,

2013 to provide a common understanding from which to generate discussions.

10 Context The following list is a brief synopsis of the context in which this project is being conducted.

There are approximately 85,500 people living with Diabetes in the South West LHIN and 42,000

in the London area

Up to 50% of people with diabetes with type 2 diabetes have neuropathy and at-risk feetxxiii

The South West LHIN has the 3rd highest rate of amputation among Ontarians with diabetes

(over 200 per 100,000)xxiv

According to the American Diabetes Association, over half of amputations related to diabetes

are preventable

The South West LHIN has the 2nd highest rate of hospitalizations for skin/soft tissue infection

among Ontarians with diabetes (over 700 per 100,000)xxv

Diabetic foot ulcers are the source of major suffering and very large costs for both the patient

and the health-care system, and every 30 seconds, a leg is lost somewhere in the world.

Investing in a diabetic foot care guideline can therefore be one of the most cost-effective forms

of health-care expenditure, provided the guideline is goal focused and properly implemented.xxvi

A strategy that includes prevention, patient and staff education, multidisciplinary treatment of

foot ulcers, and close monitoring can reduce amputation rates by 49-85%xxvii

There are a number of providers and health service organizations ranging from community

services through to surgeons providing diabetes foot care for the prevention, treatment, and

management of ulcers in the London area, however, they tend to work independently of one

another

The London Foot Clinic was reported to fill a gap in diabetic foot care services in the London

area and in its original form had rates of healing, proportion of wounds closed and complication

rates that were similar if not better than the results previously published in Canada.xxviii

The London Foot Clinic no longer has the original staff complement and is not sustainable in its

current form

iv

11 Current State Assessment The analysis of the current state of services for the prevention, treatment, and management of diabetes

foot ulcers in the London area revealed a number of best and promising practices are in use, however,

there is need for a new health service delivery system. This new model would have to be a system level

approach, addressing diabetes foot care needs across the continuum of care from community, to

primary care to tertiary care. It would have to fill the gap that the London Foot Clinic filled and at a

system level be sustainable, effective, efficient, and affordable. Meeting this need will require a

comprehensive, integrated series of interwoven changes in service delivery.

The outcomes of successfully meeting this need would support both the South West LHIN and Ontario’s

health strategies; but more importantly it would help clients to stay healthy or return to health more

quickly. It would directly support two of the strategies of Ontario’s Action Plan for Health: person-

centred care; and right care, right place, right time. It would also support the South West LHIN’s

strategies of improving coordination and transitions of care for those most dependent on health

services and increase the value of our health care system for the people it serves.

The aim of clients living with diabetes and the health sector is to stay as healthy and as free of ulcers as

possible for as much of the time as possible. Further, their aim is for clients to return to health as

promptly as possible if they do escalate in risk towards developing and/or having a foot ulcer.

From a provider perspective, this often seems like a simple linear transition through health services,

however, the complexities are far greater. Figure 1 below demonstrates the complexity of these

transitions. It provides a graphic representation of the client journey through diabetes foot ulcer

prevention, treatment, and management services in the London area. The key organizations are

depicted by icons and the client transitions through the services are depicted by lines. These

organizations, the services they provide are further described in the sections that follow.

v

Figure 8: Journey Map of Diabetes Foot Ulcer Prevention, Treatment, and Management Services

vi

11.1 Service Inventory

The current state assessment included a review of the services available for the prevention, treatment,

and management of diabetes foot ulcers in the London area. This exercise demonstrated that there are

diabetes foot ulcer prevention, treatment, and management services available and that these attempt

to provide the right care, in the right place, at the right time. However, it also revealed that there are

some capacity issues, as evidenced by the wait times cited for these services.

In addition, the service inventory identified that clients with diabetes foot ulcers are often sent to an

inappropriate provider and/or for services at the “wrong” time. An example of being sent to the

inappropriate provider is a client who is sent to a vascular surgeon when debridement of his/her ulcer

and offloading would be the appropriate services and could be provided in the community. An example

of receiving services at the “wrong” time is a client who is sent to a foot care nurse when he/she has a

foot infection and an ulcer.

Best practices in management and prevention of the diabetic foot as outlined by the International

Working Group on the Diabetic Foot are:

1. Regular inspection and examination of the at-risk foot

2. Identification of the at-risk foot

3. Education of patient, family, and healthcare providers

4. Appropriate footwear

5. Treatment of nonulcerative pathology

Best practice in ulcer treatment is outlined as follows:

Relief of pressure and protection of the ulcer (offloading, non-weight bearing, proper footwear)

Restoration of skin perfusion

Treatment of infection

Metabolic control and treatment of comorbidity

Local wound care

Education for patients and relatives

Determining the cause and preventing recurrence

It was noted through the service inventory that although there are services offered for the prevention,

treatment, and management of diabetes foot ulcers such as orthotics for offloading and foot care

services3, when they are not services covered by OHIP or insurance they may not be accessed by clients.

The diabetes foot ulcer prevention, treatment, and management services offered in the London area are

summarized in the table below.

3 Foot care services include:

Treatment for corns, calluses, ingrown toenails, and thickened toenails

Cutting and filing of toe nails

Foot hygiene

Advice on proper footwear

Education about proper foot care

vii

Organization Diabetes Foot Ulcer Prevention, Treatment, and

Management Services Diabetes Foot Ulcer Prevention, Treatment, and

Management Providers

Primary Care Providers

Management of diabetes on the whole, including proper glycemic control

Regular foot and/or lower leg assessments, by some

Referrals to other providers including CCAC foot care services, wound care, endocrinology, the London Foot Clinic, surgeons

Education regarding diabetes and foot care

MD in the community, these may be sole practitioners

MDs and NPs that work in FHTs, FHOs, CHCs, NPLCs, etc

South West Community Care Access Centre (South West CCAC)

Support in management of diabetes on the whole, including proper glycemic control (all providers)

Regular foot and/or lower leg assessments (all nurses, PSWs and CSWs)

Diabetes foot care, including non-aggressive debridement (PSWs, RNs, and RPNs)

Wound care for foot ulcers (NCs)

ABI assessments (Red Cross Care Partners - NCs)

Sharp debridement (Red Cross Care Partners - NCs)

Enterostomal care (ETs)

Consultations to other staff members on wound care and enterostomal care (ETs)

Education regarding diabetes and foot care (all providers)

Nurse Clinicians (NCs)with advanced wound care training

Registered Nurses (RNs)/Registered Practical Nurses (RPNs) with foot care training

Enterostomal nurses (ETs)

Community-based Nurse Practitioners (NPs)

Personal Support Workers (PSWs) and Community Support Workers (CSWs)with training in foot care

London InterCommunity Health Centre – Diabetes Education Programs


Regular foot and/or lower leg assessments (RNs)

Diabetes foot care, including debridement, in some cases (RNs)

Education regarding diabetes, foot care, nutrition, exercise, system navigation, services available, etc (all providers)

Purchased service available free of cost to the clients through the clinic:

o 1 RN with advanced foot care training

Have access to consultation with/referral to 2 wound care specialist through the LIHC Health Outreach for the Homeless Program for “in-house” clients

1 Social Worker

2.5 RN and Diabetes Educators

2 Registered Dietitians (RDs)

1 Community Worker

viii




London Foot Clinic Support in management of diabetes on the whole, including proper glycemic control

Regular foot and/or lower leg assessments (all providers)

Diabetes foot care, including debridement (RN)

Wound care for foot ulcers (RN and MD)

Offloading (Orthotist)

Education regarding diabetes and foot care (all providers)

Dr Bill Thompson, specialist in infectious disease

1 RN wound and foot care nurse

1 orthotist with advanced training in diabetes

London VON Flex Clinic

Support in management of diabetes on the whole, including proper glycemic control

Regular foot and/or lower leg assessments

Diabetes foot care, including non-aggressive debridement

Education regarding diabetes and foot care

Provide Chronic Disease Self-Management Program

RNs/RPNs with advanced foot care training

Parkwood – St Joseph’s Health Care London

Full lower limb assessment of all patients from which they are assigned to a risk category (RNs and NC)

o Includes glycemic control; vascularization assessment, sensory neuropathy assessment

Aggressive debridement of wounds (RN and MDs)

Prescribe (MDs): o Dressing care o Offloading devices o Antibiotics

Utilize a global approach to treating diabetes, but patients’ primary care physicians implement the care plan

Clinic operates 2 days per week

1 FTE RN with wound care training

1 Nurse Clinician

1 part-time RN

Dr David Keast – family physician with wound care training

Dr Mervat Bakeer – family physician with wound care training

ix




Diabetes, Endocrinology and Metabolism Clinic Primary Care; Diabetes Support Program; and Diabetes Education Program – St Joseph’s Health Care London

Diabetes, Endocrinology and Metabolism Clinic

Endocrinologist provide specialized diabetes management

Produce research on diabetes Primary Care; Diabetes Support Program; and Diabetes Education Program

Provide diabetes care, support and education to those diagnosed with diabetes to marginalized communities and individuals without a family doctor or NP

Offer a chronic disease residency program


All team members provide foot and/or lower leg assessments

If there are “red flags” on the foot exams an MD or NP examines the client

Diabetes foot care provided by VON foot care nurse

Aggressive debridement provided by Dr Mervat Bakeer

Diabetes, Endocrinology and Metabolism Clinic

10 endocrinologists Primary Care; Diabetes Support Program; and Diabetes Education Program

3 physicians o Dr Stewart Harris o Dr Mervat Bakeer - expert in chronic disease

and wound care o Dr Sonja Reichert

1 NP and CNS in diabetes

1 NP expert in diabetes primary care

0.6 FTE Social Worker

1 FTE RN and Diabetes Educators

2 FTE RD and Diabetes Educators

Purchased services available free of cost to the clients through the clinic

o Chiropodist o Foot care nurse from VON

London Health Science Centre

Wound care for foot ulcers (SWOT and MDs)

Infectious disease care for diabetic foot ulcers

Vascular surgery to revascularize the foot

Plastic surgery to debride diabetes foot ulcers

Orthopaedic surgery to address diabetic foot mechanical deformities

Endocrinology

Dialysis o Implemented assessment for diabetic foot

ulcers to all clients with diabetes

Skin, Wound and Ostomy Management Team (SWOT)

4 Nurse Clinicians and Enterostomal Therapy Nurses

1 APN, CNS, and Enterostomal Therapy Nurse Surgeons

Orthopaedic surgeons ( Dr Mark MacLeod)

Vascular surgeons (Dr Adam Power)

Plastic surgeons (Dr Chris Scilley) SW LHIN Renal Network

16 nephrologists

6 NPs MD specialists in infectious disease

x




Independent podiatrist/chiropodist

Assess, diagnose prescribe and carry out treatments including minor surgical procedures, and therapeutic treatments of:

o Bony Foot Deformities o Subcutaneous Lesions o Corns / Callus / Warts o Nail Conditions o Biomechanical Dysfunctions o Orthotics / Orthopedic Appliances

Numerous providers in the London area

Independent orthotist/pedorthist

Biomechanical assessment of the foot

Offloading

Proper footwear

Education about diabetes foot care

Numerous providers in the London area

xi

Analysis of best practices, current services in the London area, and input from key stakeholders suggests

that a new service delivery model is needed. One that is grounded in person-centred care, integrated,

effective, efficient, and sustainable.

Six key critical elements of a successful future state delivery model for diabetes foot ulcer prevention,

treatment, and management services were identified.

1. Education – of patients/clients and their caregivers/family and of providers

2. Interprofessional Team – to deliver holistic diabetes services that include foot care

3. Regular foot care/lower leg assessments – patients/clients, physicians and foot care providers

are regularly assessing diabetics’ lower legs and performing regular foot care

4. Access to Services – strengthen access to all diabetes foot care related services in a timely

manner and ensure that physical access is easy

5. Relationships Between Providers – strengthen relationships with specialists, hospitals, diabetes

education programs, and primary care providers

6. Monitoring diabetes – monitoring diabetes to prevent diabetic foot ulcers but also to support

healing and decrease additional complications because of inactivity, etc.

Although these are presented separately, they are closely interrelated. Many of these critical elements

also have multiple benefits, including greater patient/client engagement and control over their own

health, improved service delivery, and decreased cost. Therefore, while these drivers are presented

independently, it is important to consider them as a whole.

12 Critical Elements of the Future State Service Delivery Model for Diabetes

Foot Ulcer Prevention, Treatment, and Management This section describes each of these critical elements in detail. It includes backgrounds as to why each

of the critical elements was identified, the benefits of applying the driver to a new service delivery

model, and barriers that need to be considered in developing a successful model and its implementation

plan.

12.1 Education

Education is a key driver of change in a multitude of ways. These can be summarized as education of

clients and their care givers and/or family, as well as providers. This can be further broken down into

categories of education for each of these stakeholder groups:

1. For prevention and management of diabetic foot ulcers

2. Regarding services available

xii

Education of prevention and management of diabetic foot ulcers

Clients

For clients the need for education to prevent and manage their feet if they have diabetes is well

documented in literature and often cited by health service providers. There is little that needs to be

restated about this need. The most effective way to prevent foot ulcers is for clients to perform lower

leg assessments and foot care.

Also of key importance is education of the management of all aspects of diabetes. Variance in other

aspects of diabetes may result in diabetic foot ulcers or may affect their healing rate.

Providers

Diabetes is a complex chronic disease and there is a great deal of information available in regards to its

treatment and management. However, stakeholder interviews revealed that provider education in

regards to the prevention and management of diabetic foot ulcers is reliant on the interest of the

providers themselves. The international guidelines for the management and prevention of the diabetic

foot are an excellent tool and are supported by other tools such as lower leg assessments. It was

reported that there is a significant dearth of education regarding prevention, treatment, and

management of diabetic foot ulcers in primary care providers.

Services Available

Clients

The Ontario health system is a complex system to navigate, as demonstrated in Figure 1 above. This

exacerbates the challenge for clients with diabetes in understanding the services available to them and

how to access them.

Providers

Similarly, interviews and research revealed that many of the providers in the London area are unaware

or under informed about the services available for prevention, treatment, and management of diabetic

foot ulcers. This is the case even on the front line of these services, for example CCAC foot care nurses

and surgeons. It is far more challenging for primary care providers, specifically sole practitioners.

Some of the services associated with best practice for the prevention, treatment, and management of

diabetic foot ulcers are publicly funded and others are privately funded. This increases the

fragmentation of diabetes foot ulcer prevention, treatment, and management services. It also requires

increased education as to what services are available, where they are available, how clients might access

them, and how they are funded.

It was reported in interviews that the most effective means of educating providers as to the services

available is outreach.

xiii

Benefits

Augments empowerment of clients over their own care

Supports person-centred care

Enhances client and provider compliance

Increases prevention of diabetic foot ulcers

Increases knowledge of diabetes and diabetes foot ulcer prevention, treatment, and

management services

Supports the “right care, right place, right time”

Enhances the capacity and capability of the community in addressing diabetes and specifically

diabetes foot ulcer prevention, treatment, and management

Barriers

The health system is fragmented

Providers have to undertake education of their own volition and at their own cost

Greater time is required with patients to educate them and that is both time consuming and

costly

There is little to no immediate outcome from education, and that can negatively affect

willingness to provide or seek education

12.2 Interprofessional Teams

Interprofessional teams were cited in interviews as a key aspect of both prevention and treatment of

diabetes foot ulcers. This was reported to be in part because of the related aspects of treating diabetes

on the whole and also because of its increase in access to services that may be required. Research

supports this driver, and specifically its effectiveness in the London area through the pilot of the London

Foot Clinic.

Interprofessional teams may also support cost efficiencies by leveraging providers to provide their full

scope of services. Interprofessional teams tend to support providers working to their full scope of

practices, for example nurse practitioners can provide onsite services to clients while consulting

physicians are available to them offsite. Further, some aspects of interprofessional teams may be

“virtual”, for example specialists, primary care providers, and foot care nurses engaging in case

consultations via the Ontario Telemedicine Network or teleconference. This may reduce unnecessary

referrals to costly specialists. Interprofessional teams that span the different levels of the health system

and different locations may decrease the time a client has to wait to see the appropriate provider. This

in turn may decrease the economic burden on the health system of progression of a diabetes foot ulcer.

The following table provides a list of the health service providers that should be included in the

interprofessional team and the role that they play/rationale for their inclusion, these are:

xiv

Provider Role/Rationale

Diabetes Foot Care Nurse Have specialized training in diabetes and wound care

Provide foot care services to high risk clients to prevent ulcers

Provide education to clients on their own foot care between appointments

Tend to work within a team and can quickly access other providers for consultation or referral

Assess clients feet more frequently than a physician or specialist

Are less costly than a primary care provider or specialist

Nurse Practitioner with Diabetes and Wound Care Training

Are oriented to person-centred care

Provide education about foot care as well as diabetes management on the whole

Can perform aggressive debridement of ulcers

May prescribe certain medicines within their scope of practice

May refer clients and requisition tests

Have rapid access to consulting physician for escalation regarding clients and services


Tend to work in primary care models that have higher diabetes populations because of their target population demographics

Are less costly than a physician or specialist

Social Worker Provide support to clients in system navigation

May support clients in accessing financial support for services that are not covered by OHIP such as foot care (depending on where it is offered) and offloading equipment/devices

Have experience working with the client populations that have higher rates of diabetes


Provide support with mental health, addictions issues, which are correlated to diabetes, and can be affected in those with diabetes foot ulcers because of the isolation and lack of activity associated with healing

Physician with specialized training in diabetes, wound care, and infectious disease, and/or specialist

Have advanced education and experience in addressing diabetes and diabetic foot ulcers

Provide services to clients in a timely manner if he/she is part of a greater team addressing their needs

Have access to health information of the client and can thus better treat the client

Are available for consultation or referral

Can support the education and training of other providers in the team

Tend to have close relationships to other physicians with specialized training in diabetes, wound care, and infectious disease, and/or specialists as well as hospitals which increases access to and timeliness of services

xv

Provider Role/Rationale

Orthotist/Pedorthist with training in diabetes and wound care

Can consult on footwear and foot support

Can provide offloading services

Can consult with other clients and providers on the most appropriate offloading options

Have advanced experience and training in addressing diabetes and diabetic foot ulcers

Benefits



Enhances client and provider compliance through a “one stop shop” model

Supports relationships and trust among providers and clients


Increases knowledge of diabetes and diabetes foot care management



diabetes foot care

Barriers

Physical space can be an issue to accommodate an interprofessional team

The team must be willing to work as a collaborative and integrated team in working with clients

The funding models are different for different health service providers as well as health service

delivery models making the co-location of these providers challenging

Many of these providers would have roles/positions at other health service organizations

making scheduling challenging

12.3 Regular Foot Care and Lower Leg Assessments

Interviews with key stakeholders revealed that there are numerous initiatives underway in the London

area to implement best practices in the diabetes foot care and lower leg assessment. However, these

approaches are fragmented and are not addressing the full population that requires these services.

Best practices and all of those interviewed note that regular foot care and lower leg assessments are key

to successful prevention of diabetic foot ulcers or their treatment and management. Regular lower leg

assessments provide both a baseline measurement for client lower leg health and also provide a means

of triaging high risk clients who require further services. For those who are high risk, either because of

their demographics and/or behaviours or because of health triggers such as compromised neuropathy,

regular foot care was cited as an important element of their care. Both lower leg assessments and foot

care enable timely identification of issues in the feet of diabetic clients and thus support working with

the client to address these issues and improve outcomes.

xvi

It was suggested that foot care be conducted every 6 weeks to 3 months for those of moderate risk and

weekly, if possible, for those who are higher risk. Regular foot care in addition to education was

reported to be the most important driver of change in diabetes foot care outcomes. This is closely

followed by offloading for those who show indications of developing an ulcer or have an ulcer.

As stated in the Interprofessional Team section above, lower leg assessments and foot care can be

provided by foot care nurses and therefore are less costly to the system than clients seeing a doctor.

This may also increase access to the services.

Some stakeholders interviewed had reported that they have developed “quick” lower leg assessment

tools that can be easily and quickly applied by a variety of health services providers. This enables

providers without foot care training the ability to identify issues early and consult with providers with

expertise in diabetes foot care or refer to them as needed. This may result in a reduction of the number

of providers a client needs to see prior to accessing the services they require.

Benefits

Informs both clients and providers as to the risk level of developing an ulcer



Increases ability to identify issues early and address them



diabetes foot care

Barriers

Requires education of providers to perform lower leg assessments

May increase the demand for foot care services where there is a reported limited capacity

Requires knowledge of services available in the community for the purpose of

referral/consultation by those providing lower leg assessments and foot care services

May increase the demand of providers with limited capacity to provide consultation and/or

client services

Requires education of clients as to the value of foot care services as they are typically not

covered by OHIP

Require client to seek regular lower leg assessments and/or diabetes foot care services

12.4 Access to Services

Access to services that support the prevention, treatment, and management of diabetes foot ulcers was

cited in the literature as supporting successful outcomes. Interviews with stakeholder noted that it is a

critical element of a successful future state service delivery model.

There are three areas of access that were identified in the current state assessment, these are:

geographical access; access to all services required; and timely access to services.

xvii

Geographical Access

Geographical access was reported in interviews with community stakeholder to be key for the

population being served. Those with high risk for or already have diabetic foot ulcers are instructed to

limit weight bearing activities on that foot. If clients are required to walk long distances to access

services to prevent or manage diabetic foot ulcers, it is increasing the risk of theme getting an ulcer or

increasing the time to heal.

To address this issue, stakeholders suggested that the diabetes foot care related services be provided

close to home in the community. The site should include a parking lot in close proximity as well as

public transportation. Also, it should be accessible for those who require assistive devices.

Access to All Services Required

It was suggested that if possible the interprofessional team and all service required be located at one

physical site. As described in the Interprofessional Team section, this augments the ability of the service

providers to work collaboratively and in an integrated manner to address client needs. This can also

increase clients’ willingness to seek additional services because they can easily access the services; meet

other services providers in an environment in which they are comfortable; and it decreases one step in

the process if they can book additional services at one time.

This access also decreases the client’s need to provide the same information repeatedly to different

services providers. Access to all services required at one site means that the providers at that site also

have access to the same client information.

There are some exceptions to this that were noted. Certain providers may only be onsite on a limited

basis, for example a wound care or infectious disease specialist may only be on site one day per week to

meet the needs of the site. Certain providers may require access to specific equipment that is not

available onsite or is not cost effective to have onsite. Finally, “virtual” access may be as effective for

the provision of services and more cost efficient.

Timely Access to Services

Interviews with stakeholders revealed that timely access to services is key to increasing client outcomes

in diabetic foot ulcers and their prevention. Many of the services associated with diabetic foot ulcer

treatment and prevention have limited capacity, for example there are wait time of one month or more

at the London Foot Clinic, for diabetes foot care in the FHTs, for specialist appointments. All of these

providers agree that delays in access to services adversely affects client outcomes

xviii

Often, lack of timely access service was stated to be a lack of provider capacity, however, lack of

availability of OHIP or funding (such as insurance coverage) was also reported to influence clients

timeliness In accessing services. For example, some clients might not have insurance coverage for

orthotics and therefore chose not to offload an area of the foot at risk for an ulcer. As a result an ulcer

may develop, and only then will the client choose to offload the affected area. This delay in offloading

the area may have caused the client to develop an ulcer but also has lengthened the duration of the

complication of the potential or actual foot ulcer and decreased quality of life for a greater duration.

Stakeholder interviews also revealed that those providers involved in the treatment of diabetic foot

ulcers tend to have formed relationships. These relationships support more timely responses to

consultations and/or referral and therefore increase the timeliness of access to services required by

clients. This timely response may decrease the time for which a patient has an ulcer. Should there be

greater complications such as lack of vascularization to the foot, this might be addressed in a more

timely manner if there are relationships between the service provider and the surgeon.

Benefits



Enhances client and provider compliance through a “one stop shop” model

Supports relationships and trust among providers and clients


Increases knowledge of diabetes and diabetes foot care management


May decrease the time from the development of an ulcer to it being healed or preventing it


diabetes foot care

Barriers

Physical space can be an issue to accommodate an interprofessional team; it can also be difficult

to find close to the community that requires services with parking and public transportation

access

Providers across the spectrum of diabetes foot care services must be willing to develop

relationships that support timely access to services

It may require differently funded services (i.e. private and public) to be provided at one site

13 Next Steps At the December 13, 2013 workshop, members of the key stakeholder groups for diabetes foot care in

the London region will discuss these findings and their application in a future state delivery model.

28

13.1 Appendix B – Methodology

The methodology for this project combined a number of analytic approaches tailored to gain an

understanding of the current state of prevention, treatment, and management of diabetes foot ulcers in

London and develop a future state system-level service delivery model that would leverage existing strengths

and address areas of opportunity and gaps. MNP applied an experience-based co-design approach in

conjunction with other techniques to review and evaluate the current state process, determine best and

promising practices, and develop a value-added system-level future state service delivery model.

To guide the project, both a Project Team was struck. The Project Team consisted of key stakeholders who

were directly involved with the project via funding or initiating its execution. A stakeholder list was

developed, in collaboration with the project team, of key stakeholders involved in the prevention, treatment,

and management of diabetes foot ulcers in London. These stakeholders were identified by group such as

patient, CCAC, primary care, alist of the stakeholder included in the Diabetes Foot Care Project are listed in

Appendix C. Following an experience-based co-design approach, these stakeholders were essential to all

activities in the project.

The Project consisted of three phases of work, and two foundational meetings. The meetings and phases of

the project and the key activities included in each phase are described below.

Project Launch Discussions

Working with the Diabetes Foot Care Project Team, the kick-off meeting allowed MNP to clearly understand

the objectives of the assignment, acquire all the relevant documentation and information related to the

current prevention, treatment, and management of diabetes foot ulcers in London and to set out a

comprehensive list of key stakeholders (as discussed above) from whom to collect information and

perspective.

Current State Assessment

The current state assessment included a number of activities designed to capture an understanding of the

current state of service delivery of prevention, treatment, and management of diabetes foot ulcers in

London. Elements of MNP’s experience-based co-design approach allowed the team to capture not only the

components of the service delivery model, but also the insight, perspective, challenges and desires of those

who participate in the process. MNP carried out the following activities during the current state assessment:

Interviews with the Project Team and stakeholders

An inventory of existing foot care services available in the London area

A document review, with a focus on local research, for best practices and service delivery model

Collection and analysis of data on the local current state of foot ulcer treatment and management

A map of the current care experience using an experience-based design/co-design approach

A current state workshop

29

Future State Model

During the course of the current state assessment, several opportunities for enhancement and some gaps

became evident. Investigation of evidence-based best practices, discussions with stakeholders, and

workshops with key stakeholders led to the development of a future state model to address those

opportunities and gaps. An implementation plan was developed based on the discussions of the workshop

for the implementation of the future state model in the London area. Finally, an implementation plan for the

expansion of the future state model to the entire South West LHIN was developed.

The following activities were carried out as part of the development of the future state report:

Identification of gaps/barriers to the provision of best practice foot care for people with diabetes

Interviews with key stakeholders

Development of a person-centred service delivery model that addresses those gaps/barriers and

enables best practices

Two future state service delivery model workshops and teleconferences

An implementation plan

A spread plan to the other areas in the South West LHIN

A detailed final report that includes all of the deliverables listed above

A presentation of the final report and recommended resource allocation to workshop participants

30

13.2 Appendix C – Diabetes Foot Care Project Participants

Organization Name Contact's First

Name Contact's Last Name Role (Orthotist, MD, NP, client, etc)

London Intercommunity Health Centre (LIHC) – Diabetes Education Program Anne Finigan DEP Coordinator

London Intercommunity Health Centre (LIHC) – Diabetes Education Program Michelle Hurtubise Executive Director

St. Joseph's Primary Care Diabetes Program – Diabetes Education Program Mervat Bakeer MD

St. Joseph's Primary Care Diabetes Program – Diabetes Education Program Elisabeth (Betty) Harvey NP

University of Western Ontario – Interprofessional Diabetes Foot Ulcer Team Karen Campbell

Professor and Chair, Department of Epidemiology and Biostatistics, School of Medicine and Dentistry

University of Western Ontario – Interprofessional Diabetes Foot Ulcer Team Pamela Houghton Professor, School of Physical Therapy

Interprofessional Health & Research, University of Western Ontario – Interprofessional Diabetes Foot Ulcer Team Carole Orchard

Associate Professor, Arthur Labatt Family School of Nursing

London Diabetes Foot Clinic Sheri Green RN

London Diabetes Foot Clinic Kaveri Gupta MD

London Diabetes Foot Clinic Bill Thompson MD Infectious Disease

London Diabetes Foot Clinic Kim Trotechuad-Allen Orthotist

London Health Sciences Centre Paulo Darosa Enterostomal Therapy Nurse

London Health Sciences Centre Mark MacLeod MD (Orthopaedic Surgeon)

London Health Sciences Centre Adam Power MD (Vascular Surgeon)

London Health Sciences Centre Heather Shephard Director, Cardiac Care and Respiratory Therapy

Ontario Renal Network JulieAnn Lawrence NP

Ontario Renal Network Janice McCallum Director, Renal Services at London Health Sciences Centre and Regional Director

Ontario Renal Network Barb Wilson NP

Carole Echlin patient advocate

Health Zone Nurse Practitioner Lead Clinic Mary Stover Administrative Lead

London Intercommunity Health Centre (LIHC) Roxanna Le RPN

31

Organization Name Contact's First

Name Contact's Last Name Role (Orthotist, MD, NP, client, etc)

Southwest Ontario Aboriginal Health Access Centre (SOAHAC) Carlene Mennen RN

Thames Valley Family Health Team Steph Ouellet Clinical Director

Thames Valley Family Health Team Beth Vreugdenhil RN

ParaMed Garry Turmel Lead

Red Cross Care Partners Beth Byrnes Regional Manager, South West

Red Cross Care Partners Denise Gilchrist

Red Cross Care Partners Rose Wilson Operations Manager

Revera Home Health Catherine (Cathie) Gernaey RN Branch Manager

Revera Home Health Helen Lyons Regional Director of Operations, Ontario West

Saint Elizabeth Health Care Eileen Cunningham Regional Director

South West CCAC Darlene Bogie Regional Manager, Quality

Victorian Order of Nurses, Grey Bruce Christine Vallis-Page Executive Director

Victorian Order of Nurses, London Middlesex Elgin Gail Sadler Executive Director

VON Canada-Middlesex-Elgin site John Prisciak External Relations &

VON Canada-Middlesex-Elgin site Julie Smith Business Development Manager

South West LHIN Lindsay Declercq LHIN data analyst

South West LHIN Rose Peacock System Design and Integration Lead

South West LHIN Gordon Schacter Primary Care Co-Lead

South West LHIN Tricia Wilkerson System Design & Integration Quality Improvement Specialist

London Health Sciences Centre Chris Scilley MD Plastic Surgery

St Elizabeth's Flex Clinic Paula Day RN

St. Joseph's Wound Management Clinic Parkwood Hospital David Keast MD Wound Care

St. Thomas Foot Clinic Rick van der Heide Chiropodist

St. Joseph's Health Centre Mary Mueller Director, Medicine Services

32

i Healthcare Materials Management Services. HMMS01723 – RFP – Consultant for Diabetes Foot Care Project. May 2013 ii Ibid

iii Source: statscan.gc.ca

iv Healthcare Materials Management Services. HMMS01723 – RFP – Consultant for Diabetes Foot Care Project. May 2013

v Ibid

vi Source: statscan.gc.ca

vii Bakker, K., Apelqvist, J., Schaper, N. C. and on behalf of the International Working Group on the Diabetic Foot Editorial Board

(2012), Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab. Res. Rev., 28: 225–231. doi: 10.1002/dmrr.2253 viii

Most responsible diagnosis (MRDx) is the one diagnosis which describes the most significant condition of a patient which causes

his/her stay in hospital. In cases where multiple diagnoses may be classified as "most responsible", the diagnosis causing the greatest length of stay (LOS) is coded as "most responsible" on the hospital discharge abstract. The most responsible diagnosis may not necessarily be the same as the admitting diagnosis. Several studies have shown similarities between this diagnosis, principal diagnosis, and primary diagnosis. ix Data Source: Ambulatory All Visit Problem Dx and External Cause , MOHLTC, IntelliHEALTH ONTARIO, extracted January 9, 2014 x Ibid

xi South West CCAC. South West Diabetes Regional Coordination Centre (RCC)Diabetes Foot Ulcer Data 2010/11

xii Ibid

xiii Shannon, R. A Cost-utility Evaluation of Best Practice Implementation of Leg and Foot Ulcer Care in the Ontario

Community. Wound Care Canada. Vol5. Suppl1 xiv

International Diabetes Federation and the International Working Group on the Diabetic Foot. Put Feet First Prevent Amputations

– Diabetes and Foot Care. Time to Act. 2005 xv

Bakker, K., Schaper, N. C. and on behalf of the International Working Group on the Diabetic Foot Editorial Board (2012), The

development of global consensus guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab. Res. Rev., 28: 116–118. doi: 10.1002/dmrr.2254 xvi

Bakker, K., Apelqvist, J., Schaper, N. C. and on behalf of the International Working Group on the Diabetic Foot Editorial Board

(2012), Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab. Res. Rev., 28: 225–231. doi: 10.1002/dmrr.2253 xvii

Source: http://iwgdf.org/ xviii

Registered Nurses Association of Ontario. Nursing Best Practices Guideline: Shaping the Future of Nursing. Reducing Foot

Complications for People with Diabetes. March 2004, Revised in 2011. xix

Source: http://diabetescare.nshealth.ca/guidelines-resources/professionals-and-patients/professionals/foot-resources xx

Ogrin, Houghton, and Thompson published their findings of Effective Management of Patients with Diabetes Foot Ulcers:

Outcome of an Interprofessional Diabetes Foot Ulcer Team. 2013. xxi

This risk stratification has been married to the IWGDF stratification through equating Levels 0 and 1 to Low, Level 2 to Moderate

and Level 3 to High xxii

A Diabetes Education Program provides the tools and skills needed to support people living with diabetes so that they can lead a

more full and healthy life. In both group settings and one-on-one counselling, individuals learn self-management skills from a team of health care professionals - including Diabetes Nurse Educators and Registered Dietitians - and can develop life plans to help both minimize their symptoms and delay or prevent the onset of diabetes complications. Source: http://www.health.gov.on.ca/en/public/programs/hco/options/diabetes.aspx xxiii


(2012), Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab. Res. Rev., 28: 225–231. doi: 10.1002/dmrr.2253 xxiv

South West CCAC. South West Diabetes Regional Coordination Centre (RCC)Diabetes Foot Ulcer Data 2010/11

xxv Ibid xxvi

Bakker, K., Schaper, N. C. and on behalf of the International Working Group on the Diabetic Foot Editorial Board (2012), The

development of global consensus guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab. Res. Rev., 28: 116–118. doi: 10.1002/dmrr.2254 xxvii


(2012), Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes Metab. Res. Rev., 28: 225–231. doi: 10.1002/dmrr.2253 xxviii

Ogrin, R, Houghon, P, and Thompson, W (2013), Effective Managment of Patients with Diabetes Foot Ulcers: Outcomes of an

Interprofessional Diabetes Foot Ulcer Team. Int Wound J 2013 1-10. Doi: 10.1111/iwj.12119

APPENDIX A

South West LHIN Diabetes Foot Care Project December Workshop Background Document

December 10, 2013

Diabetes Foot Care Project Draft Final Report · 2014-10-27 · 2 Draft Diabetes Foot Care Project...

Documents

Transcript of Diabetes Foot Care Project Draft Final Report · 2014-10-27 · 2 Draft Diabetes Foot Care Project...