Case study

North Western Toronto Ontario Health Team

The North Western Toronto Ontario Health Team (NWT OHT), serves a population of approximately 415,000 in North York. This region has a larger proportion of residents over the age of 80, with 80% of the population consisting of visible minorities, and nearly 60% facing challenges in accessing basic needs. Furthermore, the presence of numerous renal/dialysis programs has resulted in a large number of complex patients with expensive, chronic health issues. These factors contribute toa higher proportion of end-stage disease and urgent health problems requiring Emergency Room (ER) visits at Humber River Hospital (HRH).
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Background and goals

Given the aforementioned demographic profile of patients in the NWT OHT, there are notable strains on geriatric care services, including Home Care and Long-Term Care (LTC). Significant socio-economic and systemic barriers to health care exist within this region, with inequities in access to specialty and preventative care.

NWT OHT has made a conscious effort to address the disparities in access to proven pathways, specifically Limb-Preservation Care, with the "Own Health" program serving as an example of an efficient and sustainable model.

Partnership approach

The partnership approach undertaken by the NWT OHT involves providing essential services to improve patient care and reduce ER visits. With the implementation of the Own Health pathways, they have successfully established specialty clinic access for primary care physicians and the community, resulting in an impressive 80% reduction in diabetic foot ulcer-related ER visits over the past two years.

Additionally, their SCOPE and LTC+ programs have effectively diverted visits away from ERs and inpatient hospital services, providing support for primary care practitioners in the community and to care teams at 12 LTCs, leading to an 80% reduction in ambulance transfers for residents with chronic wounds.

Implementation and challenges

Our work within the NWT region has been divided into several phases, starting with the development of an direct-entry integrated care pathway for patients referred with active wounds, primarily from ER and other specialists. Subsequently, efforts were made to increase community awareness and encourage referrals to the clinic, in lieu of ER visits. 

Recognizing the significant number of chronic wounds in LTC facilities, Own Health developed a dedicated pathway to assess and manage LTC residents, with ongoing support for doctors in the LTC homes to avoid the unnecessary transfer of residents to hospital. As a result, all 12 LTCs are now directly connected to the Own Health platform. 

Operational and logistic adjustments have focused on optimizing existing infrastructure, providing direct support to stakeholders/physicians, raising awareness among primary care doctors, and advocating for patients without OHIP coverage or residential status.

Outcomes and impact

Over the past six months, Own Health in collaboration with NWT OHT has made significant progress, with 112 patients from LTCs and the community receiving Limb-Preservation Care, circumventing countless ER visits. This system has resulted in an 80% reduction in ER visits related to foot wounds and a 60% reduction in hospital admissions for the same issue.

Particularly noteworthy are the achievements within the LTC pathways. Although not all complex wounds can be completely healed, due to patient factors and other determinants of health, we are still able to provide meaningful care, and symptom improvement, which prevent costly transfers for hospital-based and specialist services. Moreover, Own Health has taken pioneering steps by becoming the first surgeons to regularly attend LTCs, delivering care to residents while facilitating communication with families in order to promote an understanding their loved ones' health condition and care goals. We have also extended support to community centers such as Black Creek and Unison - organizations that serve patients with limited resources and often no access to OHIP, demonstrating our commitment to these underserved populations despite financial constraints.

Looking ahead, the partnership between Own Health and NWT OHT remains strong, with plans to submit funding proposals to expand and scale our integrated care pathways. Our future initiatives include deploying an HCCSS pathway similar to pathways established in Mississauga, fine-tuning the pathway for LTCs, and seeking monetization strategies and funding support to continue to develop and sustain this work.