Province considers overhauling wound-care treatment

TheStar.com – Ontario/healthzone.ca
August 9, 2010.   Theresa Boyle, HEALTH REPORTER

Malton resident Rick Carroll can’t even venture a guess at the number of at-home nursing visits he’s received over the last 18 months.

“Initially they came every day. Now it’s twice a week,” says the 63-year-old diabetic, whose left foot is still mending after the big toe was amputated in January last year. Visiting nurses change the dressings on his wound and remove dead tissue.

Poor circulation and nerve damage, not uncommon for those with diabetes, also resulted in Carroll’s right leg being amputated below the knee five years ago.

Patients like Carroll are major consumers of health-care resources. The annual bill for treating venous leg ulcers and diabetic foot ulcers in Ontario is $511 million, according to a 2007 study in the journal Wound Care Canada.

“The government has spent more on me in the last few years than it did in the previous 50 years combined,” Carroll acknowledges.

But budget pressures and the exploding diabetes epidemic are forcing Ontario health-care providers to rethink the way these services are provided. There is a growing realization that patients like Carroll could be better served at a lower price, by coordinating services and paying for products that cost more upfront but help speed healing.

The journal study pegged possible savings from improved treatment practices in Ontario at $338 million annually, or a whopping 66 per cent of current spending.

At the same time, the quality of care could be vastly improved. The study suggests patients could experience 33 per cent to 57 per cent fewer infections, fewer lower extremity amputations, increased healing and improved quality of life.

A more conservative savings estimate of $50 million per year was offered earlier this year in a joint report from the Ontario Association of Community Care Access Centres, the Ontario Hospital Association and the Ontario Federation of Community Mental Health and Addiction Programs.

Leading the way in overhauling wound-care treatment is the Central West Community Care Access Centre, one of 14 such organizations in the province that connect patients with community health services.

It began putting theory to practice in April by launching a project in the western GTA aimed at improving care while saving money, with the help of the University of Toronto’s Rotman School of Management.

Dr. Brian Golden, chair of Rotman’s health sector strategy, says the traditional way of offering this kind of home care has served neither patients nor taxpayers well.

“The experience is not as good as it should be,” he said at a breakfast speech at the university, hosted by Longwoods Publishing, in June.

Such care has typically been uncoordinated because it has involved multiple community health-care agencies and multiple health professionals, Golden said. One agency sends a nurse to a patient’s home, another dispatches a personal support worker and another an occupational therapist.

Many of the nurses involved are generalists, not specialists in diabetic foot ulcers, Golden noted. Best practices aren’t always followed. For example, using a certain sandal can take the pressure off wounds, speed up healing and reduce the number of nursing visits needed, but many care providers aren’t aware of that.

More upfront investment can save money long term, Golden said. For instance, “We can invest in more expensive dressings that require only two visits per week to the home and fewer nursing visits (overall).”

He pointed out that neither community care access centres nor the province’s assistive devices program cover the cost of air casts, which can also speed healing of foot wounds. Air casts are $250 boots that encase an injured foot inside an air cushion, in turn encased by a hard shell.

“The idea for this project is to heal the wound faster, quicker, better, and to make sure that everybody in the circle of care is in the communications loop and knows what they are doing so that you look at the person as a whole being,” said Margaret Mottershead, CEO of the Ontario Association of Community Care Access Centres.

To this end, a single agency will be responsible for all aspects of a patient’s care — not only healing the wound, but addressing the causes. In the case of a patient with diabetes, a dietitian could be sent to the home as well as a nurse who specializes in wound care and a chiropodist who specializes in foot care.

“We have to start seeing the full person — from the foot ulcer, to the diabetic, to the full person,” Golden said.

As a result, people like Carroll might even be spared the trauma of amputation.

“If they can save money and spare people from going through what I went through, then they should do it,” he says.

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