OTTAWA — Three years ago, when Yvan Charron’s legs began retaining fluid and swelling, just leaving his apartment became a struggle. Then, ulcers started appearing on his calves and feet, the result of poor circulation and nerve damage from diabetes.
By the time he showed up at a hospital emergency room, an infection had festered, turning the tissue surrounding one of his toes black. The toe had to be amputated.
Following surgery, Charron started receiving home nursing visits. Three times a week, nurses cleaned and bandaged his lower limbs, ensuring that relatively minor cuts and sores were treated before they became serious.
Last summer, Charron was enrolled in a test program aimed at overhauling Eastern Ontario’s wound-care services. The program was also designed to provide him with better medical observation and followup, which could reduce the risk of another amputation.
“The nurses tell me, ‘If you’re a diabetic, don’t treat (the ulcers) as nothing,’” Charron says. “That’s how I lost my toe.”
Patients such as Charron, 57, are major consumers of health care. In Ontario, the annual bill for treating venous leg ulcers and diabetic foot ulcers is $511 million, according to a 2007 study in the journal Wound Care Canada.
At the Champlain Community Care Access Centre (CCAC), which connects Eastern Ontarians to home and community health services, more than 40 per cent of the 3,600 clients who receive nursing services require care for ulcers, surgical wounds or trauma injuries. That translates to more than 1,400 clients a year.
With budget pressures and an exploding diabetes epidemic, health officials are realizing that targeting the neediest patients, such as Charron, will lead to better care at a lower price, especially if services are co-ordinated, red tape is eliminated and supplies are purchased up front to speed healing.
The journal study pegged the possibility for savings at $338 million annually, or a whopping two-thirds of current spending. A more conservative savings estimate of $50 million a year has been offered by the Ontario Association of Community Care Access Centres, the Ontario Hospital Association and the Ontario Federation of Community Mental Health and Addictions Programs.
Beyond the potential for curbing costs, the overhaul is being driven by a recognition that patients with wounds tend to receive poor care. Some go to clinics to have their wounds treated, but there often isn’t any followup.
In particular, diabetics, who are vulnerable to foot wounds that can lead to amputation, lack access to preventive foot care because visits to chiropodists are not covered by public health insurance. Because of the disease, many diabetics have lost so much sensation in their feet that there is no pain to alert them to potential danger, meaning they often continue walking on sore, infected legs. When complications arise, they cycle in and out of hospital, which is expensive and ineffective, experts say.
Brian Golden, a University of Toronto management professor who helped design the overhaul, says the traditional way of providing community-based wound care has not served patients or taxpayers well. The CCAC farms out such care randomly to multiple home-care agencies and professionals. The lack of co-ordination can lead to unnecessary red tape and service delays, he said. In addition, many nurses are not specialists in diabetic foot care, meaning the best treatments are not always followed. For example, using a certain sandal, even if it’s more expensive, can take the pressure off wounds, speed healing and reduce the number of nursing visits needs, saving a lot of money in the end. Yet many care providers aren’t aware of it.
Under the overhauled program, the Champlain CCAC has started deploying teams of case managers who specialize in wound care to organize services around patients. It has also assigned a single provider, Carefor Health and Community Services, to be responsible for all aspects of a patient’s care, from treating the wound to addressing any underlying causes.
In the case of diabetics, that could mean sending a dietitian to the home as well as a nurse who specializes in wound care. Through his CCAC case manager, Charron was connected to a family doctor and foot-care clinic.
Since the program was launched last June, the Champlain CCAC has seen a substantial drop in the time it takes patients’ wounds to heal, says Claire Ludwig, manager of client services. The goal is to reduce avoidable hospital visits by wound-care patients by 10 per cent, Ludwig says.