Downtown East Toronto Ontario Health Team

Diabetes

Lower Limb Preservation Uses New Technology for Diabetic Foot Wound Care

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Unity Health Toronto’s St. Michaels Hospital, in collaboration with DET OHT, is studying the impact of a digital health tool called MIMOSA Pro in improving the assessment and care of foot wounds related to diabetes, also known as diabetic foot ulcers.

Manufactured by Toronto/Halifax-based tech startup and approved by Health Canada, MIMOSA Pro is a pocket-sized tissue imaging device that uses near-infrared (NIR) light to accurately and non-invasively assess tissue health. It analyzes indicators such as tissue oxygenation and temperature to suggest tissue health beneath the skin’s surface. NIR light is very useful in detecting oxygenated and deoxygenated blood, which conveys a comprehensive picture of the healing capacity of acute and chronic wounds.

“A foot wound is a serious complication of diabetes that puts a person at risk of leg amputation,” says Dr. Charles de Mestral, Vascular Surgeon at Unity Health Toronto’s St. Michael’s Hospital. “MIMOSA will help our team – including vascular surgeons, chiropodists, and nurses – in tailoring wound care plans to help ulcers heal more quickly.”

Lower Limb Preservation Program and MIMOSA Pro Technology

St. Michael’s Hospital acquired this technology to support the goals of the DET OHT Lower Limb Preservation Program with funding and support from Ontario Health and Boehringer Ingelheim Canada through the 2024-25 Digital Health Care Transformation Challenge. This funding is aimed at addressing healthcare challenges and health inequities among patients with chronic diseases through innovative digital solutions.

The Lower Limb Preservation Program will measure success through key outcomes, including wound healing of diabetic foot ulcers, the number of amputations, and patient-reported experience measures. By tracking these metrics, the team will demonstrate effectiveness of a novel digital health technology in reducing preventable lower limb amputations, and improving wound healing rates through early and effective interventions.

Early Intervention Saves Limbs

Evidence suggests people with diabetes are almost 20 times more likely to be hospitalized for a non-traumatic lower limb amputation compared to the general population. Furthermore, 85 per cent of the lower limb amputations related to diabetes or peripheral artery disease are preventable through effective initiatives, including screening of at-risk feet and timely and appropriate treatment of foot wounds.

Current wound assessment and treatment planning often rely on basic physical examination techniques, which can lack objectivity and consistency across providers. MIMOSA Pro seeks to address this by providing an objective, standardized, and comprehensive assessment to guide diabetic foot wound management. While the technology used by MIMOSA Pro to monitor tissue health is not entirely new, the innovation lies in its size and strength to incorporate AI analytics for real-time, point-of-care insights. This allows clinicians to make more informed decisions, detect infections and low tissue oxygenation earlier, and improve client care by identifying issues that would otherwise remain invisible during standard physical examinations. Additionally, all data collected by MIMOSA Pro, including bedside wound imaging, is held in a secure cloud-based server without any patient identifying information.

“My expectation is that with MIMOSA Pro, we can better predict the healing trajectory of wounds,” says Dr. de Mestral. He emphasized that early detection of warning signs will likely lead to faster wound closure. “Seeing changes over time with every visit will help us more objectively assess and accelerate the wound healing trajectory.”

Dr. de Mestral and his team at St. Michael’s Hospital are committed to integrating MIMOSA Pro into routine diabetic foot ulcer assessment and treatment, viewing it as an opportunity to define a model that can be scaled and replicated across other healthcare settings in Canada.

“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.

Putting Feet First: DET OHT Unveils New Strategies to Reduce Lower-Limb Amputations

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A project from the Downtown East Toronto Ontario Health Team (DET OHT) is implementing new tools to help improve foot screening for people living with diabetes and vascular conditions in the downtown core.

The fear of losing a limb is often profound for people living with diabetes and peripheral artery disease. According to a study, peripheral artery disease and diabetes, together, account for more than 80 per cent of lower limb amputations in the country. However, regular foot screening can be a major contributor in preventing most amputations and foot complications.

While analyzing the care gaps in the downtown core, the Lower Limb Preservation (LLP) project team within the DET OHT uncovered significant disparities in the preventive and timely delivery of foot care. They recognized challenges encountered by both clients and providers in accessing support services and navigating the complex health care system.

The analysis underscored the need to have a simpler process of screening and referring patients with foot wounds and complications.

In primary care consultations of clients with diabetes and vascular conditions, foot screening often takes a back seat to other complications, such as stroke, coronary ischemia, blindness, and kidney damage. To encourage timely screening, the LLP team at the DET OHT has developed a foot screening and risk management instrument for providers. It allows them to follow three simple steps: ‘Look’ for wounds, ulcers, and signs of gangrene; ‘Touch’ and check palpable blood flow in the feet; and ‘Ask’ about pain in the resting position of feet and/or toes.

The outcomes from these steps assist providers in determining the subsequent stages in a client’s foot care journey, ranging from education for low-risk patients to directing high-risk individuals to specialized clinics.

“Patients may not be fully aware of the risks and importance of foot health, and they often struggle to determine when and where to seek help for foot-related concerns,” says Sandra Fitzpatrick, Regional Facilitator for Toronto Diabetes Care Connect, a regional program led by South Riverdale Community Health Centre.

While there are numerous barriers hindering timely and appropriate access to foot care, Sandra says financial constraints are a significant challenge. Many individuals need to pay out-of-pocket for chiropody and foot care services and find it exceedingly difficult to afford private foot care. As a result, they face barriers in accessing preventive foot care and resort to overcrowded hospital emergency rooms, if complications develop.

Similar to primary care, specialized foot care is also facing overwhelming demands.

“Chiropody clinics are operating at full capacity,” says Teresa Salzmann, a chiropodist at Anishnawbe Health Toronto, who provides specialized care to vulnerable individuals in the Indigenous community. “Over the last couple of years, there has been a significant increase in moderate to high-risk cases that require escalation of care.”

Experts in the field say clients accessing specialized foot care experience varied and lengthy clinical journeys, and may fall through the cracks.

Fitzpatrick and Salzmann have played a key role in enhancing the efficiency of client navigation. Together with clients, who offered valuable firsthand insights into challenges accessing foot care, they have developed a visual pathway outlining prognoses and corresponding actions. This helps providers to take appropriate measures to mitigate the risk of complications and potential amputations. Additionally, the pathway recommends specialized referral clinics to primary care providers participating in the program, catering to different types of wounds and complications identified during screening.

The LLP team has extended an invitation for participation to family physicians who operate outside of team-based settings and do not have access to specialized foot care, including Ministry of Health-funded chiropody clinics.

The main objective of the project is to ensure that everyone receives appropriate foot care at the appropriate time. To achieve this goal, the DET OHT aims to substantially reduce the number of lower-limb amputations over time. However, in the short term and with the help of measures enhancing screening and escalation of care, the team is focused on making foot care an equal priority as other complications of diabetes.

Lower-Limb Care Program of the DET OHT is Gearing Up to Launch

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The Lower-Limb Preservation (LLP) demonstration program of the Downtown East Toronto Ontario Health Team (DET OHT) is gearing up for launch in October 2023. The project consists of two working groups, namely ‘Screening and Prevention’ and ‘Escalation of Care’, which are leading these efforts. Both groups are focused on addressing the critical foot care needs of individuals receiving care in the Downtown East area.

The goal of the Screening and Prevention Working Group is to enhance the regularity and consistency of foot screening. It has been observed that individuals with diabetes and/or peripheral artery disease, who are at a higher risk of developing foot complications, often do not remove their socks for screening during their consultation visits. Therefore, this working group is developing a foot screening tool to help identify risk of complications and care needs for appropriate and timely referrals.

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