Downtown East Toronto Ontario Health Team

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“The real secret sauce – the magic ingredient – was the structure underneath the pathway”: design thinking expert reflects on the lower limb care strategy

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We engaged in a dialogue with Julian Goss, a design strategy consultant with the Downtown East Toronto Ontario Health Team (DET OHT) Lower-Limb Preservation (LLP) project. Goss specializes in incorporating design thinking, process, and practice into healthcare strategies. He played an instrumental role in defining key elements of lower limb care, and helped integrate these elements to develop a client-focused design for the LLP pathway. During this discussion, Goss shared his thoughts on the model’s strengths, feasibility, and scalability.

Looking back, what were some of the initial thoughts and considerations when you and the LLP team were in the process of developing the clinical pathway for lower limb care?

Julian Goss: They were not so much as thoughts, but rather concerns. One of my concerns was, does this pathway reflect feasibility, and what assumptions are we making? After developing a pathway, key stakeholders such as primary care providers, solo providers, chiropodists, or vascular surgeons have a role to play. Once we include them as either means or ends, how do we ensure what we are asking or hoping that they will do is within their capacity – that it is not impossible to do? The other concern was, are we clear on the value of user journey? The values are in a form of five W’s: who is here? What are they doing? Why are they doing it? When in the patient journey or condition is it happening? What level of care needs to happen?

From a design perspective, what insights and outcomes have emerged from the pilot demonstrating the pathway’s scalability?

Julian Goss: The pilot demonstrates the feasibility and scalability of the pathway, which has become an integrative pathway, leading to a big AHA! moment. We realized that ‘screening and prevention’ and ‘escalation of care’ is a continuum. Although they could exist in parallel for different circumstances, they are essentially a continuum. So I have been working under the assumption that once we can tell Ontario Health what we did, how we did it, and the results we have accomplished, we can say that this is now scalable and this is what we need. There is always some kind of resource, like time or money. Hopefully, we have got a very strong value proposition and its impact is cost effective. Preventing someone from losing a lower limb is a lot cheaper than dealing with someone with an ongoing condition of having an amputation.

As a process design expert, could you share your insights on what typically occurs in a complex system like health care that takes away from the clients’ pathway?

Julian Goss: I can give you a couple of design-situated perspectives. First, the solution that we came up with is not just a pathway. The differentiator in this pathway is what we built underneath – the communications structures, connectivity, and conceptual clarity. When you come across a beautiful, simple design, it is tip of the iceberg. The undergirding of a structure that enables it to function is systemic thinking. One of the many problems that healthcare shares with other sectors and organizations is having a complex adaptive system – meaning, it constantly changes and shifts. However, like most organizations, healthcare is working on a good, static organizational framework, which will always lag behind what is really going on.

Secondly, design has a lot to do with subjectivity, particularly product design where you have to work in the head of a consumer – know what they think about, what they need, and how they react. However, in healthcare, there is no guarantee that the nurses and physicians will see the problem on the same scale as we are seeing it. They will look at it with the lens of their capacities and training. A design expert tries to acknowledge that and create a shared mental model of the larger perspectives.

In conclusion, would you like to add something or share a key takeaway from our conversation?

Julian Goss: It is really important to share with everyone involved in the project and tell them, we did good work here – thank you! The other thing I am curious about is when we present our story to Ontario Health, I would be really interested in knowing whether they can look at something like this and resonate with this approach; when we tell them we pulled in a design capacity and it helped us arrive at an apparently simple solution. But the real secret sauce – the magic ingredient – was the structure underneath the pathway.

“The hope is that everyone is getting care from the right place at the right time”: Two health care providers discuss timely intervention and prevention for lower-limb care

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We engaged in a dialogue with two of the physician leaders of the Downtown East Toronto Ontario Health Team (DET OHT) Lower-Limb Preservation (LLP) project – Dr. Curtis Handford, family physician and Medical Director of the Primary and Community Care Program, and Dr. Charles de Mestral, a vascular surgeon and scientist – both affiliated with Unity Health’s St. Michael’s Hospital site, a DET OHT partner organization. Together with interdisciplinary working groups comprising clinicians, community stakeholders, and patients, they collaborated to develop new change initiatives aimed at improving diabetic foot screening, enhancing care escalation, and expanding community-based chiropody capacity. Drs. Handford and de Mestral shared their perspectives on the program’s significance and its prospects.

Before developing and implementing the DET OHT pathway for LLP, what were some of the significant care challenges for the providers and patients?

Dr. Curtis Handford: I can’t really speak for the patient perspective directly. Although, often the providers’ and patients’ perspectives overlap. From the providers’ perspective, we know there was a lot of confusion based on the preliminary environmental scan that we completed. One of the factors is that specialized foot care services covered by OHIP were generally not available to the majority of family physicians who do not work in team-based practices and their patients. So, patients who could not afford to pay for private chiropody services were often left with other ways to try to manage their problems, and then would at times end up needing to use the emergency room because of lack of other places to go. Confusion is the word I would use for the preliminary state.

Dr. Charles de Mestral: I would echo Curtis. My perspective as a provider at one end of the spectrum – receiving people who have wounds and sometimes performing amputations – is that there is a great disparity in both preventive care and timeliness of care across all different types of people and walks of life.

One thing related to disparities is the financial barrier. One of the areas where financial barriers come into play is footwear – people are not able to get a better pair of shoes to prevent wounds or prevent the recurrence of a wound after it is healed.

How is the LLP program at the DET OHT creating awareness about foot care and preventing non-traumatic, major lower-limb amputations for patients with diabetes and vascular diseases?

Dr. Curtis Handford: Primarily the way our demonstration program is creating awareness is amongst providers by creating tools and resources that guide providers in how patients can be managed and navigated through the system. Patient or public awareness is probably a little less well-developed at this stage of the project, but is something the OHT is beginning to explore.

Dr. Charles de Mestral: I do not think there was a lack of awareness about the risk of foot wounds and foot complications before this all started. But there was probably a need to support people’s knowledge around how to deal with this problem. From a hospital’s perspective, the whole program has raised the profile of limb preservation. It has acknowledged the expertise that exists at St. Michael’s Hospital, particularly chiropody and vascular. St. Michael’s has an important role in addressing this issue – a leadership role – certainly provincially and also nationally.

Dr. Handford – just to build on the point you made earlier about resources for primary care – how does the program support primary care providers, considering the context of limited primary care capacity in the current times?

Dr. Curtis Handford: That is a million-dollar question! If you want primary care providers to spend more time dealing with feet, you have to help them save that time somewhere else. In order to do more of something, they are going to have to do less of something else. I think the time saved is going to be through simpler navigation to cover chiropody resources and escalation to hospital-based care. We have tried to keep the screening recommendation as simple and as time efficient as possible and to not get providers bogged down in over- extensive screening of feet.

With current learnings and insights from the project, what do you hope the LLP can accomplish for the future of foot care and the overall quality of lives of patients?

Dr. Curtis Handford: For me, the hope is that everyone is getting care from the right place at the right time. The hope is that we can eliminate lower-limb amputations significantly over time. Being able to demonstrate an impact on that is a years-long, if not a generational endeavor. I think we can certainly start to see signals with the work that we have done in Downtown East Toronto by clarifying pathways for providers, providing education to the public, and ensuring we have an engaged team of partners across the Ontario Health Team.

Dr. Charles de Mestral: In the short term, perhaps, if our program can show some success based on the measures that we have for implementation, screening, and timely escalation of care, then we can maintain funding and see the lower-limb preservation become a priority at the same level as prevention of stroke, coronary ischemia, blindness, and kidney damage. And level the playing field when it comes to prevention at a health policy level provincially.

As this issue is not just contained to Downtown East Toronto, how do you think the pathway and the resources in the DET OHT can be leveraged beyond its catchment area?

Dr. Charles de Mestral: I think the screening tool is applicable in many places. There is some benefit to working within the Ontario Health Team framework, in that you can tailor the approach to screening and escalation of care to the resources that exist and tweak the capacity. The big-picture principles need to be applied everywhere and then they need to be tailored to the context people are in.

Any final thoughts and comments that you would like to add?

Dr. Curtis Handford: I am not saying that we do not still have work to do, but I will say that it is clinical pathways like this that give the Ontario Health Team the greatest chance of getting physicians excited about the work of the Ontario Health Team.

Bridging Gaps in Accessing Mental Health Care: A Conversation

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We invited Dr. Linda Jackson, Senior Clinical Program Director for Community and Primary Care* at Unity Health Toronto, to share her thoughts on some of the work underway in the DET OHT focused on mental health. Dr. Jackson is currently co-chairing the Stepped Care Pilot‘s Oversight Committee. In this discussion, which is a second installment in a two-part series on the Stepped Care Pilot (read part one here), she shares the significance of the stepped care model and how it can support both family physicians and their patients in accessing mental health services.

As a senior leader for Community and Primary Care at Unity Health, what can you tell us about the challenges that the DET OHT’s priority populations (people experiencing homelessness, mental health illnesses, and addictions) have to face to access mental health care?

There is widespread recognition of challenges among the general population in accessing mental health services, specifically counselling and psychotherapy. These challenges include difficulty in navigating organizations offering these services, long wait times, and a lack of funded or affordable services. Our priority populations experience even greater challenges, often not having the resources and supports to navigate a complex mental health system. This issue of navigating to mental health service has been identified by family physicians and nurse practitioners in the Downtown East area who frequently encounter patients presenting with mild to moderate mental health issues, including anxiety and depression, who require and would greatly benefit from accessing counselling and psychotherapy services.

In your opinion, what distinguishes the Stepped Care Pilot from other delivery models?

The stepped care model has leveraged an existing program called SCOPE to support family doctors and nurse practitioners to refer patients with mental health issues to a trained mental health navigator, who works with these patients to better understand the issues affecting their mental health and their readiness and interest for counselling and psychotherapy. Together, the mental health navigator and patient develop an understanding of the most pressing issues and the options available in the community. The navigator then ensures a warm handover by connecting to appropriate resources and staying engaged with the patient until they are linked to the resource or decide that they are not ready to pursue counselling at this time. For some patients, the opportunity to meet with the mental health navigator for initial exploratory sessions has been the intervention that was needed and they did not wish to link for further counselling.

What do you hope the stepped care model can accomplish for the mental health and addictions community of the downtown core?

The model has assisted primary care providers to link their patients to community based mental health services. It has likely prevented some patients from presenting to emergency departments for this type of navigation. The model has identified where gaps exist in accessing mental health services, which can be a focus for further planning within the DET OHT. Assisting the primary care providers in navigating resources allows greater access to other patients at a time when there are many pressures on primary care. This is particularly important for providers who do not have access to mental health services in their clinics.

Given the rise in mental health crisis, particularly after the COVID-19 pandemic, how can we support the long-term growth and sustainability of programs like Stepped Care Pilot?

The evaluation of this program confirms that patients and providers have benefitted from being connected to the stepped care model as well as the importance of collaborating across organizations to integrate care delivery. Addressing the gaps in the availability of affordable and fully funded mental health services, particularly with a trauma informed approach, should be a focus of the DET OHT to support the sustainability of this program.

*Update – Oct 22, 2024: Dr. Linda Jackson retired from her role as Senior Clinical Program Director for Community and Primary Care at Unity Health Toronto in June 2024.

“This is the first time I have had privacy, housing – my own space”: ED Outreach Worker Program Ensures Sustainable Care for People Experiencing Homelessness

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Precarious housing is a mounting crisis in the city, and recently declared an emergency by the Toronto City Council. People experiencing under housing and deep poverty also have difficulties in navigating and accessing social services, such as housing and income support, which directly affect their health.

One in five patients who visits the Emergency Department (ED) at St. Michael’s Hospital is precariously housed. In an effort to support patients with challenges beyond health, the community partners and members of the Community Advisory Council of the Downtown East Toronto Ontario Health Team (DET OHT) have developed the Emergency Department Outreach Worker Program.

With the aim of helping patients facing unstable housing situations achieve stability and long-term support, this program assigns a dedicated outreach worker to each individual in need. The outreach worker’s role includes securing housing, ensuring access to meals, finding sustainable sources of income, and, if required, providing legal assistance. Presently, the program has one outreach worker on staff.

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Transforming Health Accessibility Using the Digital Shared Care System

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In a step towards creating a more seamless care experience for patients/clients in the downtown core, the Downtown East Toronto Ontario Health team (DET OHT) launched a pilot project that focuses on improving care pathways between organizations for people experiencing precarious housing and facing health accessibility challenges.

The aim of the ‘Digital Shared Care System’ pilot project is to digitally connect organizations to share patient/client information in a safe and timely manner that adheres to all privacy legislation to address gaps in care, improve efficiency and provide a better care experience for patients/clients.

According to the City of Toronto’s Street Needs Assessment Report 2021, more than 7,300 individuals are facing unstable housing situations in the city and those who are chronically under-housed (experiencing unstable housing for six or more months in the past year) are six times more likely to report two or more health challenges.

The DET OHT’s Digital, Privacy, and People Experiencing Homelessness Working Groups implemented a tool to allow a Team Member organization that is a health information custodian (HIC), St. Michael’s Hospital, and one that is a non-HIC, Fred Victor, to collect and share common client/patient information.

Some of the patients visiting the St. Michael’s Hospital Emergency Department (ED) are also clients of Fred Victor. Previously, the HIC and non-HIC care teams had to share clinical notes and acute care documentation manually, as there was no secure digital communications channel. This process increased the teams’ administrative workloads and delayed sharing of coordinated care plans, doctor’s notes and follow-up appointment schedules.

Furthermore, it was a challenge to ensure clients’ seamless care journey within the ED, especially during busy periods with longer wait times. It became even more difficult to track clients who left without receiving care.

The Digital Shared Care System pilot allowed for the implementation of a tool for the St. Michael’s and Fred Victor teams to address these challenges.

Now, when a Fred Victor client agrees to register in the system, the St. Michael’s ED Outreach team works with Fred Victor’s Case Managers to create care plans and document health management alerts online. This digital process has reduced delays by improving information wait times and has relieved the care teams of significant administrative work.

“The digital platform has allowed St. Michael’s to share critical patient/client information with a non-traditional health and social service partner in a more timely fashion,” says Ahana Sarkar, DET OHT Digital Working Group and Project Lead.

“It has reduced information wait-time from 30 days to four to six days, greatly improving the coordination of care between the two teams. This is a huge initial win for the pilot.”

In addition, SMH ED Outreach Workers and Fred Victor’s Case Managers believe their working relationship has further strengthened due to efficient communication and coordination. Case Managers can now get regular updates on their client’s health records, with the consent of their clients, even if the client was not able to inform them of the hospital visit.

“It is an extremely useful tool for accessing client health records to be able to provide better service,” says Stella Iacobelli, Life Skills Housing Worker at Fred Victor.

“There are times when our clients go to the hospital, but we do not know why they went, and they are not able to tell us. We can now check this platform and find out exactly what is going on with someone and where they need our help with a follow up.”

Currently, 137 patients/clients have given their consent to be registered in the system to receive comprehensive care, including healthcare, shelter/housing referral, food security, social support, and long-term case management.

Recently, the project team and end-users convened to evaluate the impact and outcomes from the pilot implementation and the evaluation supported the extension of the pilot for an additional six months.